private practice they have been involved in activities that do public service. we are, by nature, citizen lawyers. you don't work as hard as we work, reach where we've reached unless we've shown that to the powers that be. we get selected because we're the very best at some aspect of the work that we've done. and that work often includes public service. so it means that there isn't one of us who is unaware of political life. we're aware of it. we read the newspapers, we listen to the news. some of us are political junkies, others are not. but become an informed citizen doesn't get translated into now i'm going to vote the way the public wants me to. the gift the founding fathers gave us is they gave us a

lifetime job so that we wouldn't feel pressure to do a decision based on public opinion from fear that somehow we will be driven from our work. and so we're not thinking about public opinion in terms of reaching the answer that we believe the law compels. every year, if you read our most sensitive decisions, you will see us recognizing the impact those decisions might have on people. in every sensitive opinion the court is very aware when one of its decisions is going to be particularly difficult for some people in the society. it's recognized in our writing. but we do take pride on the fact that we are voting according to what we think the constitution

or the laws require. that means that we can be aware of what the effect will be. we can even acknowledge it. but that's a different thing from letting it determine the outcome of a decision. [ applause ] now, would the students please not leave? i'm coming down now. i would like to take a picture with the students who are here because they took the time to come up with a creative question. and they deserve a picture. and maybe as i'm walking down the next student can ask me the question so i get through more of those than not. and my security detail will talk to me later about being late. [ laughter ] >> i know that all of you will join me in a rousing thanks of

appreciation -- [ cheers & applause ] -- and in -- [ applause ] >> come on. come around. come on, guys. >> as you can imagine, and i'm sure some of you are feeling, we have a few more students, a few more colleagues and friends who have questions. so we're just going to have to get her back. we hope that you'll do that. and in the meantime, many years of strength and health as you serve all of us from that

incredibly important position. we're very grateful to have you there. [ cheers & applause ] >> all right, ruth. i came down. after i broke my ankle during the confirmation hearings, i am very cautious about moving. that's why you see them helping me. i'm trying to avoid a second accident. okay? >> down here sitting? we're done. >> okay. bye-bye, everybody. thank you. [ applause ]

queen elizabeth ii will speak at the state opening of british parliament delivering a speech written by the government that outlines the priorities for the coming year. we'llcy mule cast live coverage live at 5:30 a.m. eastern on c-span 2. this sunday night on q&a, vanity fair columnist talks about his new book "old age, a beginners guide on living with parkenson's disease". >> parkinson's is a brain disease. but what i really meant obviously was thinking, sit going to affect my thinking. and thinking is how i earn a living. so that became pretty important. and i asked this neurologist what's going to happen.

and he says -- he was trying to tell me it wasn't such a big deal. he said, you may lose your edge, as if that was just nothing, and i thought gee, my edge is how i earn a living. it's why i have m my friends, maybe why i have my wife. >> sunday night at 8:00 eastern and pacific on c-span's q&a. representatives from the va and advocacy groups talked about mental health and suicide prevention program to assist veterans and their family members and the barriers that kbis to receiving treatment. the house committee hearing was led by its chair, representative jeff miller. it's two and a half hours.

committee will come to order. thank you for being with the committee for today's overnight hearing entitled come bathing the crisis, evaluating efforts to prevent veteran suicide. as the hearing title suggests, we're here to discuss the ongoing veteran suicide crisis that according to the latest data available, found 22 veterans a day dying at their own hands. i'm disappointed that the v acti a when nouz able to release updated suicide statistics at this time for the hearing. i understand that the center for disease control finally provided national data to va in the middle of march. considering the critical interest in updating veteran suicide data, i can't emphasize

enough the need for the va to pursue analysis with a sense of urgency. it is my fer vant hope, as a result of the investments we feel maid in va mental health care. i'm hope that witnesses today could provide more recent -- and to shed some light on whether the efforts dedicated to this crisis are indeed making any impact. the rates in suicides have risen significantly in the past 15 years for almost every single demographic, except for veterans. i think that is due in large part to the hard work that va

health care providers do every day, to extend helping hands to those most in need. but that is not to imply that the current rate is in any way acceptable. i continue to be concerned that again, according to the latest data from va that is admittedly dated, the number of veterans dying by suicide have not fallen, despite significant increases in budget, staff and programming. it's not enough for the veteran suicide rates to remain stable. our work will not be over until rates are eliminated. there are many reasons someone may choose to take their own life and there are many

opportunities for someone to step in. v action should be glad that the veteran suicide rates have not riz, along with the swren population. but there's clearly a disconnect between the services and support that va offers and the veterans that most need our help. care. particularly for someone that is contemplating suicide is not one size fits all. and while suicide undoubtedly is a mental health issues, it is also much more than that. eliminating suicide altogether will take a comprehensive approach to ensure that those most at risk have not only the care they need, but also a job, a purpose and a system of support in place to help carry them through their struggles. therefore, va must adopt a suicide prevention strategy that

recognizes a need for wrap-around services that treats patients as individuals, and embraces complementary and alternative approaches to care where appropriate. furthermore, va needs to better integrate a family and veteran perspective that incorporates the lessons learned from those on the front lines of the fight against suicide and can offer a message of hope to those who are still struggling today. last year, the clay hunt suicide prevention for american veterans or s.a.v.e. act was signed into law. clay hunt returned from the battle from afghanistan but in 2011 lost his personal battle from the demons he brought home with him from those conflicts. the law included a number of providers that i believe will

help connect the veterans with both the va and their communities that will provide valuable information about what programs are working for veterans in crisis, and assist va in recruiting high quality mental health -- fully implementing the clay hunt s.a.v.e. act should be va's highest priority. i look forward to discussion the department's progress to date. in clay's memory, in the memory of the countless other veterans who have lost their lives to suicide, we have to do better. with that, i yield to the ranking member ms. brown for an opening statement she may have. >> thank you, mr. chairman for calling this hearing today. strong oversight of the suicide prevention program remains a

priority of this committee. we are all aware of the often cited statistics of 22 veterans a day committing suicide. we also know that va reports in 2014 that there is a decreased rate of suicide among users of the veterans health care system with mental health condition much the question becomes how can we ensure ready access to safe quality mentality health service of veterans in need of care. i hope the va witnesses here today will be able to update us on those numbers as much of the country was not included in previous estimates. my subject that concerns me relate to the new my va 12 break through priorities. i understand that addressing the suicide problem is not one of those. increased access to health care and proven comprehension and pension exams, continuing to reduce homelessness and transform the supply chains are

all on the list, but specifically reducing suicide is not included. given that suicide nationally is considered by some to be a public health problem, i believe va should include suicide prevention as number one my va priorities. i look forward to the testimony on this and where suicide prevention fits into the 12 priorities. i still believe that suicide prevention should be one priorities of their own, top priority. mr. chairman, this hearing will also examine and implement the clay hunt suicide prevention for american veterans act passed in the early days of 114 congress. this law focused the nation of

this terrible epidemic affecting veterans. this law requires that the secretary of veterans affairs and the secretary of defense to arrange for an outside evaluation of their mental health care and suicide prevention. it also requires any service member being discharged to have their care reviewed for any evidence of post traumatic stress disorder, tray ma brain injury or military sexual trauma. we've been at war for over 14 years. there are many veterans out there who do not engage the va care system for purposes of mental health treatment. veterans from all areas. today the discussion should include how va is going to reach out to these veterans. and i definitely want to say that one of the major problems -- and i thank the va for having the conference on suicide prevention that i was able to attend. but one of the points that was

pointed out that many of the veterans, even those we have 22, only three of them are involved in the system. and many of them are vietnam veterans who when they returned home wasn't received properly. so we need to figure out how we're going to reach out to these veterans and include them in the system. with that, mr. chairman, i yield back the balance of my time. >> with us is dr. jackie massfuchi, joy elam, thomas berger were the executive director of the veterans health council for the vietnam veterans of america, and kim ruoko, the chief external relations officer for suicide prevention and post prevention for the tragedy assistance program for survivors.

we're also joined by va's assistant under deputy of secretary of health who is accompanied by dr. harold cuddler and dr. katelynn thompson. thank you all for being here today to testify before our committee. there, you are recognized for five minutes. >> thank you, chairman miller. thank you for the opportunity to share our views on this crate call issue. in 2014 -- this campaign centers around the principal that timely access to mental health care is critical. the signing of the clay hunt save act into law was an important first step.

we thank richard and suz. for inspiring us all to do the right thing, congress for passing the legislation and the va for their kmpment to fully implement the law. we're pleased to be included in the process. we're committed to working with the va and our partners. personally i've been working on this issue for about eight years and never in that time have i seen a movement around this issue so strong or a collective will so unified than in the last year. the conversations are moving to action. and it's our responsibility to make sure that this continues. so today i'd like to focus on four specific areas critical to progress. access to care, inner disciplinary approach to care, supporting those most at risk and the importance of research. and iva's annual member survey, over 80% of they continue to

f emphasize the role of family aends friends with over 75% report having a loved one suggest they seek help and as a result getting that help. three of four of the members are using the va. this year we saw over 75% of those using va mental health services report, little to no schedule challenges, un10% from last year. the same number were also satisfied with that care. but with more help seekers comes more demand. it's critical to ensure that the va is properly resourced to provide this high quality care. efforts are under way with the administration to bolster the va workforce, recruiting medical students and improving curriculum. but that's not enough. beyond the challenge of a shortage is the difficult task of hiring and retaining talent in the va. the hiring process is confusing

and lengthy. it might be made easier. the va needs to fully understand why staff are leaving, they need to know how best to attract employment. noncompetitive salaries and low moral. we all play a role in workforce moral at the va. we often for get to praise the dedicated staff who support va's mission. our members are shared stories of the great work and dedication of the staff relying how these individuals safed their lives or care for them in their hardest moments. we all must do our part to celebrate what makes the va good while also focusing on how to make it better. finally we need to ensure that high quality care exists outside va. just under 40% of the veteran population actually seeks care at the va which means the

current community clinical workforce needs to be equipped to support the veterans and their families and this is not the case. it's not even common practice to ask a military history. this has got to change. but beyond asking about military histories, the community care doctors need to know how best to provide treatment once they have the answer and the va and academic partners are best to lead this effort. it's not just about mental health care. mental health is a major aspect to suicide prevings, it's not the only aspect. there are social factors that impact this as well. for the va suicide prevent office to take a health

approach. we ask congress to ensure that the suicide prevention office is fully resourced so it can be certain to carry out its critical mission. we've also focused on veterans with bad paper. this is a community that's been identified high risk for suicide and homelessness. we can do something about this. iava urges passage of the fairness for veterans act as part of the solution but we also know we need to come up with a comprehensive solution with congress, dod and va. and yet with all of this we simply don't know enough yet. and this is where the research piece comes in. we know that suicide impacts seniors disproportionately but we don't know why. we know that women vets have a high rate of suicide but don't understand how best to intervene. this is why we support the suicide prevention act and calls for the senate to take immediate

action on the bill. we know that the post-9/11 generation are showing an increased risk but are just starting to understand the risk factors. more research and evaluation is critical. we simply cannot solve what we don't understand. the va has a wealth of research and data and they need to call upon academic to partner with them. we're asking the va to open up their data and invite academics to help be their army to look at this data and help us find the solutions. all veterans deserve the very best our nation can offer. we look forward to working with congress and the administration to address these very real challenges with informed solutions. thank you. >> thank you very much, dr. ms. elam, you're recognized for five minutes nks thank you. we appreciate the opportunity to testify on this important issue.

va as enhanced and promoted a comprehensive set of -- into mental health and primary goals. and re -- early intervention are keel to improving quality of like. promoting on and minimizing the disabling effects of mental illness and suicide. in recent years va's mental health programs have been praised and criticized. outside sources have described the scope, depth and breadth of va's mental health approaches as superior to care in the private sector. data shows that va users have a lower suicide rate than veterans not uses the va health care system. however there have been documented issues with access in the past over prescribing of medications and serious failures for some veterans, along with a call to action to do more to

prevent suicide in this population. in our opinion, va has two major challenges, one to ensure it meets to diverse needs of an increasing needs of vet raens who need specialized mental health servicesance two how to effectively outreach to veterans who are not using va but in crisis or need of help. younger veterans indicate they prefer a variety of nontraditional therapies over medication, such as web based, life coaching, yoga, meditation and acupuncture. va is steadily increasing the ability to access these. this past week wednesday a group of community based organizations sponsored a spartan weekend for ill and injured veterans on the promise that they would not take their own lives without reaching out to someone for help. the event reached 1.8 million

facebook and other social media users and resulted in a number of veterans reaching out for help for the first time. these type of community events will be essential for connecting the veterans to the mental health services they need. dav prefers va to be the provider of mental health services whenever possible. immediate access to care is critical. this group can benefit from the peer-to-peer program, substance use disorder and tbi, as well as the wrap around services and post deployment transition challenges they often face. if a veteran with mel tall health issues needs to access care, we urge the va to fol loup

up with the veteran to insure that the veteran is receiving care. another area we recommend v action put focus on is crisis management. when a veteran is experiencing a mental health crisis and asking for help, there must be ready access for mental health services. we are pleased in that regard that va has been working hard to provide training and services through its crisis line and pilot new programs for peer specialists having been found to be effective. another area we urge focus on is women veterans. according to va, the suicide rate is six times higher for women veterans compared to civilian women. however, it is encouraging to learn that women veterans who use va health services were 75% less likely to die by suicide

than women veterans who did not use va. this suggests that the mental health programs for women are showing promise and positive results and that a concerted focus on this subgroup of veterans should be continued. we do offer suggest that there be improved access for women veterans to specialize in patient and residential mental health programs to ensure recovery and effective reintegration. va must ensure that the programs meet the unique needs of women including safety and privacy concerns. we urge va to continue its training and partnerships with the community providers, improving its mental health programs on suicide prevention and to find innovative ways to engage all veterans who need these services. we can congress to do their part as well, providing va with the resources to for expansion, the staffing issues and ongoing research. it's our hope that as a community we can work together

to ensure that any veteran who needs help can get it. mr. chairman, that concludes my statement. thank you. >> thank you. dr. berger, welcome. you're recognized for five minutes. >> thank you distinguished members. vietnam veterans of america thank you for allowing us to present our testimony. the timing of this hearing is particularly important. as some of you may have read the recent national center for health statistics report that found that suicide in the united states has surged to the highest levels in nearly 30 years. with increases in every age group expect for older adults in the age group, both men and women over the age of 75. the overall suicide rate has

rai hissen by 24%, according to that report. and the increases for so wide spread that they lifted the nation's suicide rate to 13 per 100,000 people, the highest since 1986. there's absolutely no doubt that this country is in the midst of a public health crisis with suicide. and nowhere is that any more true than in the veterans community as we learned back in february 2013 with the va's report on veterans who die by suicide. and particular, that report painted a shocking portrait of what's happening amongst or older vets, my cohort and those who served before me. almost three-quarters of the veterans who commit suicide based on that report are age 50 or older, according to that report. and even though suicide has become a major focus for the

military over the last decade, most research by the pentagon and the veterans affairs department are focused on men who account for more than 90% of the nation's 22 million former troops. little has been done or focused on female veteran suicide until recently. according to an l.a. times article in july 2015 -- by the way, i have to apologize. my written testimony says july 2016. i can't read into the future and i need to get my auto correct fixed on my machine. anyway, the suicide rates are highest among young female veterans, for women ages 18 to 29. veterans kill themselves at nearly 12 times the rate of nonveterans. and according to that same "times" article, amongst that

cohort that was looked at, the suicide rate of female veterans closely approximate that of male counter parts in effect, women vets at 28.7 per 100,000 versus 32.1 per 100,000 male vets. but we also can't forget, as the chairman has alluded, that it's from that 2013 report that the figure of 22 veterans suicides per day is calculated. this number is suspect because of the data only representing numbers reported from 21 states from 1999 through 2011 and did not include states with massive veteran community like california and texas which didn't report their suicide ooh to the va at time. therefore, va calls for an updated veteran suicide report

that includes data from all 50 states and u.s. territories and also we strongly suggest that va mental health services develop a nationwide strategy to particularly address the problem of suicides amongst or older veterans. obviously i'm speaking on behalf of our vietnam veteran era group. at the same time we understand it's challenging. but we've got to overcome the barriers, identify and yof come the barriers that prevent our service members from seeking the help that they need and that they deserve. the rks dva is heartened by the efforts that the va has made since february 2016, including the effort mentioned by the doctor early. while these initiatives are

laudable, dva believes strongly they cannot be fully successful without a significant increase in the recruitment, hiring and retention of va mental health staff as well as timely access to va mental health clinical facilities, programs, especially for our rural veterans. and this committee is in a position that can ensure that our veterans and their families are given access to the resources and programs necessary to stem the tide of veteran suicide. once again on behalf of the officers board and general membership, thank you for your leadership and holding this important meeting and i'll be glad to answer any questions. >> thank you. you're recognized. >> chairman, miller, ranking member brown and other distinguished members of the veterans committee. the tragedy assistance program thanks you for the opportunity to share stories from surviving

family members of service members and veterans who have died by suicide. these families are honored to have a vice in this process and they gain healing from the thought that this testimony in remembrance of their loved one may in fact share a life. i am chief external relations officer for suicide prevention and post vengs for the tragedy assistance program for survivors. following my husband's death i joined together with bonnie carol to build the care based support program for all of those grieving a death of an active duty service member or recent veteran who had died by suicide. taft's ultimate goal is to help the families to rebuild their lives on a solid foundation after a death by suicide. tafts presently has over 7,000 survivors. for the purpose of today's

suicide -- story system, i have gathered information from family members who have recently lost a veteran to suicide. survivors of military suicide hold a wealth of information on the multiple factors that lead up to this kind of death pap they are on the front lines of a service member or veteran's battle with mental illness, moral injury and the multiple stressors associated with military life. they are witness to the challenges of sigma associated with mental health and the barriers to care for those who are suffering. survivors of veteran suicide loss can provide us a picture of potential impact of challenges within the va system. today's testimony is a summary of information gathered from these families. the first common theme was barriers to care. it's important to note in each case i have highlighted the veteran was not in ongoing consistent treatment at the va. in most cases the veteran

struggled to get the care they needed in a timely fashion. in some cases the veteran himself or herself was the first barrier to good care bawl of their cultural beliefs. this reluctance to share their true story, fear that they would not be wlooefd or insistent that they need to push through and suck it up, in combination with institutional barriers can become a perfect storm for those veterans suffering. families of the veterans struggled to help their loved one often became frustrated with and overwhelmed with navigating the system. lack of involvement in the treatment of their loved one. part of the veteran culture is not to complain or admit to emotional or physical pain and to downplay how serious their issues are. families feel strongly if they were present, they would have a

more accurate plan. it was difficult the to get the veteran to go and agree to get help. when they did do it was during a crisis period and there were long waits or inability to see someone at that time or a misunderstanding of their struggles. the second theme that was throughout all of our families' conversations was the request for peer support. in each case the family tells taps the veteran only wanted to talk to someone else who had been there. they had guilty and shame. this was a barrier in getting appropriate treatment. it eventually leads to an understanding that their symptoms are real and valid and there is treatment that works. tho so here are our recommendations based on our findings. we have toin crease the number

of mental health providers that are trained in evidence based best practices for treatment of these injuries and illness at each contact a vaet ran should will able to get appropriate mental health care in a timely manner. this is especially true in crisis points, er was on outpatient clinics. the family would love to develop groups to offer support and guidance for those supporting a veteran. number three, develop an avenue for family member to call for professional advice and get guidance on how to get their loved one into care. four, make peer support specialists a line item. peer support is an invaluable tool. peer support specialists can be used to reach out to these veterans where they are and build a bridge toward treatment and help them stay in treatment. five, increase incentives for and streamline process for peers

to become mental health professionals. in the case of veterans, personal experience adds a level of trust that greatly increases the possibilities of a veteran seeking treatment and staying in treatment. thank you for listening to us today. we have many families that came to me and would like their story heard and we have those available to you fi you would like to hear those in the future. >> thank you for your testimony. dr. mccarthy, you're recognized for five minutes. >> good morning. thank you for the opportunity to discuss the effectiveness of the department of veterans affairs mental health programs. i am accompanied by chief consultant for mental health and the national director for suicide prevention. va has developed the largest integrated suicide prevention program in the country. we have over 800 dedicated and passionate employees, including

suicide prevention coordinators, 'em deemologists, researchers who spend each day preventing suicide caring for veterans. our overarching strategy enhances veteran's ability for health care. veterans who reach out for help must receive that help when and where they need anytime a way that makes sense for each of them. we do have a good story to tell today. one in which we wish to share hope and progress. and in which we want all veterans to know that va is here to help. but the rest of the story is that we still have work to do. we're pleased to share our progress and the opinions of others outside the va about the quality of our efforts. on february 2nd we hosted a summit to bring together veterans families, other federal agencies, community partners, veteran service organizations, subject matter experts, members

of this committee and other key partners to enhance our work on suicide prevention. powerful for so many attendees were the stories shared by veterans and their families. these stories resonated with us. just as we don't prevent sudden cardiac death only when it's happening, we know that suicide prevention does not necessarily begin with our crisis line or other interventions when suicide is eminent. our efforts are about hope, finding reasons for living, leading a high quality life and developing strong meaningful relationships, engaging veterans in va care and in particular in our whole system of care is a key part of prevention. addressing their job concerns, substance abuse, homelessness, financial concerns, general medical health and of course mental health are all important steps in preventing suicide.

the call to action generated multiple recommendations and initiatives to strengthen va's approach to suicide prevention. for example, a pilot project is returned way to evaluate risk intervention strategies based on data that predict who would be at risk for suicide before these individuals reach a crisis. also, va continue to actively monitor suicide related behaviors through our suicide prevention applications network. we're working to develop a dashboard to allow us to identify possible clusters of suicide related behaviors and to trigger meaningful responses or interventions. va remeans committed to ensuring the safety of set vans, especially when they're in crisis. we do have universal access for 24/7 emergency care through our emergency departments and by va's veteran's crisis line. the program continue to save lives and link veterans with

effective ongoing mental health services on a daily basis. prevents suicide also requires have noted. between 2005 and 2015, the number of veterans who received v.a. mental health care grew by 80%, a rate of increase more than three times that of the overall growth of v.a. users. this reflects the concerted effort to engage veterans knew to our system and stimulate better access to health services. we remain committed to eliminating the stigma associated with receives mental health care. in 2007 we rolled out integrated mental hiss services, which allowed veterans to receive warm handoffs from their primary care team to a mental health provider, present in the primary care clinic on the same day. v.a. has also moved to patient-centered community care, a centralized contracting mechanism, and has implemented the choice program.

we are addressing access through our efforts such as extended hours to help increase capacity, and the hiring of over 900 peer specialists while expanding their role into primary care settings. we partner with more than 150 mental health organizations around suicide prevention. we recognize that we cannot do this alone, and we continue to develop and prioritize these partnerships. we are aware that some veterans are at an even greater risk of suicide. we have individual and group-specific intervepgss tailored to helps in rick for any receipt advance is wub me wu continue to address.

website that provides easily accessible information about the mental health services for veterans. currently the v.a. facility is accessible on several sites including va's hole page includes contact and resource information for a variety of mental health programs. mr. chairman, the crisis aof su s side is remaining focused on providing the highest quality of care while trying to understand more about prekurcursorprecurso. we appreciate the support of congre congress. and we will be happy to respond to any questions you may have. thank you. thank you very much, doctor. could you -- you talked about having contracted a review of your suicide prevention programs and other outreach efforts.

when -- when do you expect to receive the final product from that review? they have started their work. i think we are due to give you a report about august, but in two years, their review will be complete. hopefully an interim report in august. >> yes, sir. >> when we are on our summer work period? >> we'll happily do it whenever it's convenient. >> as soon as possible. thank you and then i think it's important for the committee to know and understand what's the tony time that it takes from bringing a mentality health provision on board? i can tell you the process, and it likely takes several months. when asked about the actual vacancy rate of psychiatrists, i

believe the doctor can testify we're at about 236. we are working -- >> out of how many? 236 out of. >> i have it in my notes somewhere. >> i believe it's about 800. >> and as we continue to hire and expand, some moved around, and then we had vacancies. there's turnover in mental health. the psychologist -- there's a lower rate of vacancy. >> go ahead and talk about the process of recruitment going all the way to bring through something on board. >> so typically there's advertisement. people apply often through usa jobs.

the applicants are reviewed. interviews are conducted. they a cresse denchaling process that's sensitive to how quick the information is imported to the credentialing process. they need in there relatively quickly. after that, an offer is made and a start date is given. i -- i do not have the average time. i would be happy to get back to you on that. >> we talked a bit about the clay hunt suicide peru vent act. according to figures that i have, because of the enroll machined period been extended, there have been almost 1,000 veterans enrolled into the v.a. health system. what have you learned from those roughly 995 individuals in

regards to your outreach to them and, you know, what can be done to provide more information about current programs? >> thank you, sir. tone are xwsh pell inkem v.a. health care. we have that we're currently ongoing with our health el general office to try to decrease any barriers, to help have every person leaving the military have a health plan when they leave. we've done that especially already for people that have been engaged in mental health

care, but this is for all of them, to have the health care plan when they leave. what we are looking at is not automatic enrollment, but essentially close to that, so that if they haven't chosen or indicated another health care system, we would like to decrease any bureaucracy, and get them enrolled very quickly. >> what are the biggest barriers you've heard that they feel like they have to overcoupled? >> on some level there's a sense that some veterans do not understand they are entitled to care. and for our vets who are post-9/11 leaving that five-year eligible level, there really should be no barrier. we have treated women veterans who said literal any a clinic, i didn't know i was eligible for service. so we have to change or messaging to be more welcoming to all our veterans, as much as we try, we have people at outreach events, our sued side coordinators to giv outreaches. >> we go to the welcome home ceremonies, but something is not happening. >> so the person -- who is the

first person? >> thank you, mr. chairman. i want to thank all the witnesses for your testimony. i also want to make a pitch to you, mr. chairman. mr. kauffman held a wonderful reception for a group of people from colorado that did a wonderful video, in which you're part of the future. and i hope that we can do something to encourage the committee to take the time

i haven't seen it but i understand it's good. >> very good. very powerful. it is long but i think it will give committee members other ideas we need to follow and follow through on. >> the director, stephon tubs >> well, the director, mr. tubbs, is a very impassioned advocate. >> well, it's certainly -- it's certainly -- i intend to show it at events at my district. and it's a very bipartisan -- a very bipartisan video. anyway, my -- i have some questions for i believe it's the va about taps. i understand that taps has a -- is a big supporter of peer-based counseling. you recommended in testimony that peer support specialist should be a line item in the

budget. what do you recommend that va do better with regard to their peer support program? >> well, i know there's about 900 out there now, but there needs to be more. we need more money to get that program built bigger than everywhere. because what our families told us they had a lot of trouble getting their veteran to the va. they had a lot of misconceptions about what would happen there. they don't understand treatment. they are afraid of treatment. they're afraid of being overdrugged. and so it -- they would not go to the va until they were in crisis. and then it's very difficult to get immediate mental health care when you're in crisis, where we'd rather have them in the system before the crisis getting treatment. so, these peer specialists have done everything from going and finding a homeless veteran to bringing them to the va and getting them into the system to getting them housing, to sticking with them and to describing what treatment is to say i went there. i had the same symptoms.

i went there and i'm better. so, they can really be a bridge for all of this. because i think one of the biggest challenges is not getting our veterans who are suffering into good evidence-based treatment for the treatments they are suffering were from these wars. and all of my cases are ones who fell through the cracks. they all died by suicide. and every one of them i talked to had tried to go to the va, had tried little places but didn't go until they were in crisis and then it was very difficult to get the treatment they want when they were already in crisis and so many things that already interfered with their lives. >> dr. berger? >> i think it's misleading to say that -- generalizing and say 900 peer support persons have been hired. it makes it seem like they're all in mental health when that's not true. okay? so, i think we need some answers about how many peer support people do we actually have in mental health. >> is there a response to that question? >> so, the number that we quoted

are primarily mental health or part of the primary mental health integration program, so they're linked to being the ones that reach out and encourage the veteran to receive care. >> do we need -- do we need to fund this more? do we need to fund more? how much more do we need to fund it? >> is that for me, sir? >> yes. >> it's my understanding there's two pieces, right? there's the peer support specialists that are the training, but then there's also an avenue for peers to become mental health providers. right? that's two straight things. so, having peers, veterans who have been there, get the training to be mental health counselors in the system, is a win/win for both because we're taking those veterans who had this experience and are able to use it to do good and to save other veterans. so, it's two different tracks. we're talking about peer support specialists to go out into the community to get them into the va and we're talking about a streamline of getting peers, veterans, trained in mental health to be counselors.

two separate pieces. >> my question is, is there adequate funding? if not, how much more do we need? >> i don't have that. but we'd be happy to get back with you on that amount. >> please. >> thank you. can i just clarify the number i gave as the number of vacancies? i'm sorry, chairman miller, we currently have 550 on-board psychologists and 2,300 on board psychiatrists in va. and so when i talked about 236 vacancies, it's 236 out of 3,203. >> okay. >> thank you, mr. chairman, and thank you for having this important hearing today. dr. mccarthy, the bill that we passed, the clay/hunt suicide prevention act for american veterans, requires the va to collaborate with nonprofit mental health organizations to do three things -- to improve the efficiency of

suicide prevention efforts. to assist other nonprofit organizations to do a better job and to collaborate with these nonprofit organizations. what is the va doing, and how are these collaborative efforts coming along? >> so, i did mention before our call to action summit that happened in february. that's one piece of it. we really brought a lot of people together. not for us to tell them, but for them to tell us what we really need to be doing, what we need to keep doing, what we need to do better, what we need to do differently. more than that we sponsor community mental health summits around the country, and this is our fourth year of doing it. each medical center sponsors a summit, in which information is shared bidirectionally. our homeless outreach folks have

done that and mental health has been doing that. we've learned and we've shared. and it's been extremely productive for the collaboration. one other thing we've been doing is actually working with partners in the community who provide care. we realize that especially as part of choice there are veterans out there receiving mental health care and we want them to have a warm welcome reception in the community just like we want for them to have that at va. we've developed in partnership with dod a military competence training for providers. it's -- provides up to eight hours of continuing medical education free for community providers or internally, for people to be able to understand the language and about taking a military history. we've also lobbied to have cpt code added for taking a military history, which is part of a reimbursement mechanism in the private sector so that people will be encouraged and

financially rewarded for doing that. >> okay. thank you. and dr. berger, i'd like to ask you a question about research, and i think we all agree there needs to be more research. you said that about 70% of veteran suicides are people of the -- among males is people of the age 50 and older. according to your chart, 85% of male veteran suicides are age 40 or older. >> well, sir -- >> so, my question is -- my question is, when -- let's say vietnam-era veterans who served 40 to 50 years ago, let's say between 65 and 75 -- 1965 and 1975, tell us about the connection between that service and a suicide at the age of 70 or something like that? i understand probably every suicide is for unique and personal reasons. but what can -- what does research tell us about the

connection there? >> well, certainly -- excuse me, sir. there are risk factors that all veterans share. there's no denying it. but at the same time as we age, there may be additional risk factors added to the pool. for example, in the case of our older vets, it may involve insurance, health insurance kinds of things, if they're not enrolled in the va in particular. there may be family issues. that surface at that time. the structure in our lives changes. but at the same time i'm not aware of any folk cuss geronitological research on the different aged cohorts and which risk factors may be important at particular points in time. >> okay. thank you.

and i appreciate the work of every one of you on the panel. our hearts go out to those who have committed suicide at whatever age, and so thank you for your preventive work. mr. chairman, i yield back. >> thank you. ms. bradley, you're recognized. >> thank you, mr. chairman. and i wanted to thank you for bringing up the female veteran suicide prevention act. and i am encouraging all of you to help in supporting this bill. we have a companion bill in the senate, and i certainly would like to see this particular piece of legislation see it through. because i think the focus, although dr. berger talked about -- i believe you talked about an increase in being able to treat women veterans, i think it's really critically important that the va is the expert, the absolute expert, in this issue around suicide and particularly looking at best practices for both our male and female veterans, because i do think a

female experience on the battlefield can be very different from a man's experience. so, thank you for that. i also, you know, wanted to talk a little bit about the outreach. and i know that we have a transitional program to have a warm handoff when our veterans leave the service from the dod to the va. and i think that that's positive. i'm curious to know how well that's going and what it looks like. but i think we have to actually dig back further. in other words, you know, it seems to me we should have medical professionals on the battlefield there. i think in terms of outreach with family members, i think we need to, for -- for a veteran who is sent to the battlefield who is potentially going to experience trauma, the family members should be trained and prepared so on their re-entry back the family members need to

i think in terms of outreach with family members, i think we need to, for -- for a veteran who is sent to the battlefield who is potentially going to experience trauma, the family members should be trained and prepared so on their re-entry back the family members need to know. and when we talk about older veterans, which for the first time today i'm aware that the suicide rate amongst older veterans is going up, you know, we've got to figure out some kind of outreach in those cases as well. but i do think that -- i think, you know, we train our men and women to go to the battlefield and be prepared to save their physicality and their physical health, but we also need to prepare them to survive their mental health as well. and so i think we have to go further back, starting really at

the beginning, so that people are knowledgeable and aware. even the veteran can be aware of their own behaviors and help themselves. so, i guess, you know, the question that i would like to answer -- or to get some answers from is, you know, really how this handoff situation from the dod to the va is really working. how do these handoffs take place. what are they looking like. and are we collecting some data on that to figure out if -- if this kind of warm handoff is actually working. i open it up to anyone. >> so, we're kind of looking at who might do this. >> i'll jump right in here, at least from the perspective, what i know about it. you know, vva has stayed away from using the term "seamless transition" because there is no such thing. i would only point out we have many, many cases where the transfer quite frankly there's

no other way to say it is screwed up, and it ends in the result -- focusing on today's topic, in a veteran suicide. for example, i'm sure you've all heard, there's at least two or three cases in the last year or so of vets who were prescribed certain kind of medication and dod for their mental health challenges they get to the outside, those records weren't forwarded to the va or there was some kind of barrier or what have you, the va gives a diagnosis, puts them on perhaps another complete set of mental health medications and they can't cope. and they take their own lives. >> dr. mccarthy, do you have any responses in terms of that response and how you believe the program is working and if what dr. berger is saying is true, how do we rectify that? >> so, i'll be happy to respond to the medication parts and i'll

turn it over to dr. thompson about the program if that's okay. thanks, tom, for bringing that up. we have had an opportunity to look very closely in our cross-agency partnerships about this particular transition time and medications. and we have made it now so that all psychiatric and pain meds that would be prescribed in dod could be prescribed in va. and it is our expectation that those meds -- the medications would continue seamlessly. however, the expectation is that the provider would do a safety review, so if, for instance, there are multiple drugs of the same class and too many, that at that point they could be adjusted. but the expectation clearly is that this go well. we started. we've done two sets of chart reviews actually looking at specifically transitioning veterans of 1,000 veterans that we checked, i believe the number was 20 that had a medication

change that was not what we expected it to be. that's 20 too many. and so we provided feedback to those providers who made that change and we've also increased our education program specifically about meds. but i'd like caitlin to talk about the transition program. >> well, my time has run out, but maybe we can follow-up. i yield back, mr. chairman. >> thank you. dr. rowe? >> i'll yield my time to answer the question. >> thank you, sir. so, we also have what's called the in-transition program which is a coaching model so that vet -- service members who are -- who have difficulties with mental health are given a coach while they're still in service, who then help them and make sure that they have that transition point across -- across to the va, but we really take all of this extremely seriously, especially because we know and for older veterans, but also for others, that those veterans who are going through transition in any way are at very high vulnerability for suicide risk. >> okay. thank you. i want to start by, first of all, thanking the va. i think you all have -- i think

you do have the largest comprehensive mental health program in the united states, and it's not perfect, but it's certainly better than it was seven years ago, when i first got here, 7 1/2 years ago. there's no question the focus the congress has given and the va has given has improved things. one of the things that's hard to do in suicide, and, first of all, as a practicing physician, was to identify those people who are at risk. because it's a silent demon that you carry around, you don't care with anyone. i think one of the things we've learned today is that when patients, veterans, do get into care at the va their suicide rate has gone down. we've figured that out. number two, we've learned that the hiring process at the va is ridiculously long and should be shortened not just for mental health but other providers for health care.

i think that's got to be shortened. i don't know what takes so long. i've hired multiple physicians in my career and it doesn't take that long. it's not that hard to do to do your background checks and so forth to find out what you need. i think the other thing that has been brought up, and what is confusing about this, is when you look at the data -- and i think the cohorts of people are different. for instance, us guys, vietnam-era guys, that's a different cohort than the younger veterans that are leaving. when you look at the suicide data among -- from 2001 to '7, nondeployed veterans had suicide rates higher than deployed veterans which is confusing for us. the fact that we -- i mean, why does that happen? so, i think more research is important. and i think one of the things that we have to do, family and friends and being -- there is no question, i looked at data years ago when i was in practice that showed that somebody that went to a psychiatrist who had a higher rate of suicide than somebody who talked to their best buddy. so, having a good friend to talk

to and having someone you point also out very clearly, i think you need to expand this program that you can touch a buddy who was in the service. those of us who served have a different view of the world and so forth. if you have someone who has put their overalls just like you have, i think it makes a big difference. i think that's a program that works, and it should be expanded. the other thing i want to encourage you to do in the va and outside the va is good, good data, because without that you can't make the right decisions. you just cannot. and you can't just group us all into one big group. you got to look at different cohorts, female, younger veterans and older veterans like i am. so, i'll stop there and let anyone make a comment. >> so, maybe i could mention the data analysis that's going on right now because we're excited about this. this is very different from what we did in the past where we had to get data from the states and some states gave us data and

some did not. we have worked with cdc and with dod and have requested data on everybody that had been in the military or the va between 1979 and 2015. and so we sent multiple disks with data that could be matched with the cdc data for suicide. and it's coming back to us. it's very raw. it involves a lot of individual checking and so forth. we so wanted to have the data to share with you at the hearing. we don't. we were told that it would be analyzed by the middle of the summer and we promise we'll get it to you as soon as we can. but we're really excited, because this is not state specific, and it crosses ages, sexes and all those other kinds of risk factors that we really want to be able to identify and we want to make that data available to our academic partners in a transparent way so others can help us understand the data. >> two things that was said and dr. berger pointed it out, the 22, just saying 22, well, that

is probably not correct. because if you look it was just 21 states. it probably isn't correct and yet that's quoted all the time. that's why we need accurate data. and in the u.s. we're 50th in the world in suicide. i'm proud of the fact that we're really pointing out, because it all comes down to one person. look at all this data. it doesn't matter when you're the one person, the one patient out there, the one veteran or civilian, that's contemplating taking their life. it's preventable. it's just like opioid addiction and death. those are preventable deaths if we pay attention. i yield back, mr. chairman. >> thank you very much. mr. custer, you're recognized. >> thank you very much, mr. chair, and thank you, dr. rowe, for setting up my comments on the opioids. because as i sit and listen -- and, by the way, this is one of the best panels i've heard since we've been here. but as i sit and listen, excuse me, there's so many corollaries. i'm a co-chair of the bipartisan

congressional task force on -- to combat the heroin epidemic, and we now have over 80 bipartisan members and we're passing 15 bills this week. and i want to commend my colleagues on both sides of the aisle and jackie for her work on veterans. we passed yesterday the promise act. but there's so many corollaries, and many of the same people, four out of five heroin users, have a co-occurring mental health disorder, often undiagnosed and untreated. but i wanted to speak to you particularly, ms. -- i'm sorry. first of all, my condole lenss for your loss, but thank you for your courage. >> thank you. >> and a big part of this is about stigma. it's about mental health generally and the stigma around mental health.

so, one piece i want to convey to you is that we want to help. help you to be a leader on addressing stigma and particularly for veterans. in new hampshire i'm very proud of a new program that we have that's called ask the question. and we're using this across the state. this is way beyond the veteran community. this is our entire health care community, mental health community, every person that comes in contact with anyone who comes before them to ask the question, did you ever serve. my father was a world war ii pilot, spent -- was shot down. he was a p.o.w. for six months. no one ever asked him this question. he never talked about it until he was well into his 70s, and it was only when my boys growing up started asking him all the questions, what was the plane like, what happened to you. what do you mean.

what happened after you hit the ground, you know, tell this story. so, i'm curious about this peer support, because this is what one of my communities has just started for heroin use. >> yeah. >> and it turns out that incredible psychological bond of someone who's been before you. and if you can talk more about how can we help you to grow that program. and then just generally for any of the witnesses, how can any of us here help with the stigma and the support. and then just lastly, really want to commend a candidate -- and i don't mean this to be partisan. to be honest, i don't even know his party, but this is in yesterday's politico, one candidate's risky vet talking about his ptsd. he's running in delaware and he's a veteran. and it is a risky bet, but the courage for you as a family member to come forward and for

others to come forward i think is critical. >> so, thank you so much. and i'm from massachusetts, so i'm aware of that campaign, and it's a great campaign. and we actually have all been speaking together, like, kate and i work a lot together on messaging with the department of defense, and one thing we've really talked about is there is a need for all of us as a whole to change the messaging around the va and around suicide. >> good. >> you know? that number 22 that's been going around, we had a suicide in the veteran population about five months ago who left a suicide note and in the suicide note said i'm going to be one of the 22 today. why should i even try? so, having the negative messages out there that it's an epidemic, that there's 22 dying a day is increasing hopelessness in our veteran poppulation and the feeling of treatment doesn't work. it is the biggest barrier to them getting real good treatment with the demon that they're bringing with us from unresolved early childhood trauma and

additional combat-related issues. so, i think we need a campaign where we're all speaking with one voice about the people that are getting treatment, that treatment works, that more people are getting treatment and surviving than are dying by suicide, so we can get those veterans out there really thinking, do you know what, there's others who have gone through this. they've survived it, and they're doing well. because we have amazing veterans in our communities that are doing unbelievable work. and we have peer-based programs all over the country, like red white and blue and team rubicon that are pulling these people together and providing hope and are beacons about who these people really are. they are loyal and smart and dedicated. so, we've got to start a campaign that looks at that and talks about that, and stop focusing on the fact of how many have died. we've raised awareness. we know it's a problem. let's get in forums like this and fix the problem, but at the

same time get a message going out there that they -- that treatment works and it doesn't have to be that way. i think that's really important. >> my time is up. i'm sorry, we'll have to come back on another round. but i will just say i saw the other night on television the "invectus" going on this week with the sports. >> yes. >> so powerful with the hidden wounds of war. this is part of what we're going through in the addiction community an anonymity has been such a big part of this, which is important for treatment. but for those on the other side to come out and start to tell their story is so powerful. >> so powerful. thank you. >> thank you for being with us. >> thank you very much. >> thank you, mr. chairman. i, too, would like to thank you all for being here this morning. i just want to follow-up on something with dr. mccarthy that's been bugging me since

i've been around here. and i don't know, i mean, is it emblematic of what's going on? is it a sign of the sincerity of the va? but i have an issue with, when you call the va hospital and there's an automated message that says "dial one for the pharmacy, dial two for the outpatient clinic, dial three for the o.r." but if you have a mental health crisis, please hang up and dial a ten-digit number, okay? this is a pet peeve of mine, all right? and i have been working on this not only in my district, it's -- they fixed that, all right? because i've been on it all the time. but as of this morning, in michigan, the iron mountain va and the saginaw va have fixed it, but there's still three mental centers in michigan you have to hang up and dial an 800 number. i brought this up in committee a long time ago, and i'm asking why this is not fixed. they said, it will all be fixed

in six months. well, that was more than six months ago. and i'd like to know why we just can't fix this right now. why does this change take so long. you agree it should be fixed, right? >> sir, absolutely. i have good news. i have some good news. there are 12 vas where you can press one and get directly connected from the medical -- >> 12. >> -- 12, to the crisis line. >> that's what i'm telling you, it's not very many. >> which is pretty great in terms of the technology. it's not all of them and it should be all of them, that is clearly in the works -- >> this is why i bring this up, okay? because this is something that should be fixed automatically without taking a year to do it. all right? so, here we are talking about mental health crisis, all right? and you can't do this. you understand what i'm saying? we got all kind of huge problems to solve in dealing with mental health patients and you can't fix this? it is outrageous. i mean, i -- i'm amazed by this.

i mean, it hurts me. because this is -- these are blocking and tackling. this is solving the individual problems that veterans have when calling -- this is a crucial thing. i mean, i've had individuals talk to me about this very problem, you know, and they try to kill themselves in the parking lot of the va because they couldn't get help. so, i am trying to tell you, my comment here is, that this is a blocking, tackling, minor thing. these are the kind of things you have to fix every day and not take a year to do it. so, you're telling me that there's only 12 places in the country that this is actually occurring out of the hundreds of va facilities around? >> it's my understanding it was 12 the last time i checked. i know it's rolling out really quickly. >> is there somebody within the va that's resisting this change that you're aware of? >> oh, no. we have a rather old phone system and we have a number of challenges with it. >> don't tell me that. you got dial one to the pharmacy, it connects to the pharmacy just fine. do you know what i mean? so don't blame it on the phone

system. here's the other thing i want to know. when you dial this crisis line, i mean, a lot of people end up dialing the crisis line because that's the only place they can get a person, all right? so, what is the process for triageing people that call the crisis line who may not actually be in mental health crisis but they are trying desperately to talk to somebody at the va. >> let me let dr. thompson take that call because she's dworkd there. >> thank you, sir, these are very important points. by the end of the summer all of the vas will have rolled out the press seven so the press seven numbers get to the veterans crisis line. the reason that they have to phi lot it is because they have to know how many people will be available at the crisis line as they roll this out. otherwise there won't be enough people to answer those calls. >> now you are saying the 800 number, there's nobody there?

>> i'm sorry, sir? >> no, sir. >> your answer makes me suggest that you're not rolling it out because you don't have people behind the scenes to do it. >> no, we have to -- you have to phi lot things in order for -- to understand what the rollout's going to be, but i assure you that by the end of the summer all vas will be rolled out, but we absolutely understand -- >> that's what you said last year. >> this has taken -- this has taken longer than we had thought. >> we personally tested it and -- >> what about the question i just asked about the -- >> yes, sir. when people -- and i worked on the crisis line for five years. when people call the crisis line, there is a set of questions to ensure that the people isn't at immediate risk and they need somebody right away, which happens 30 to 40 times a day where somebody needs that immediate help because they're in the process of dying by suicide. they can't -- they can't commit to being safe. so, but -- >> how many questions is it? >> it varies as far as -- there's certainly, like, a few questions that are -- that are important for a suicide --

>> how long does it take? >> -- a suicide risk assessment. >> how long's it take? >> to do a suicide risk assessment? >> on the phone, yeah. >> the immediate -- the immediate question is are you safe right now really. and that's an immediate question. and then there needs to be developed a rapport with the person who is calling, so many of the people that call this is the first time they've called. >> okay. all right. i'm out of time, thank you. >> -- before. >> i would glad to give you some more if you need it. >> and i'm happy to keep answering the question but -- >> unfortunately, i don't know that your answers are what he's looking for. >> it doesn't sound like it. >> to talk about a silly pilot on something as serious as this is just ridiculous. mr. o'rourke. >> thank you, mr. chairman. and, mr. chairman, i'd like to begin by talking for bringing much-needed attention and focus and accountability to this issue. i can't think of a more important issue for us to be working on, and i think that's reflected in your leadership, and i would just ask that we continue to keep the pressure and the focus and our commitment

to provide the resources and the oversight necessary to make progress on this issue. and i think to a person we are all there with you, and the ranking member, to maintain this as a priority. and i want to thank everyone who's part of the panel today from the va and from the advocate community for your help and focus, the information that you're bringing to this, so that we can make better decisions, so that we can hold ourselves and the va accountable for making improvements. and i want to echo the ranking member's suggestion that through you, dr. mccarthy, this goes to the secretary, he has 12 wonderful priorities for transformation of the va, not one of them is specific to reducing veteran suicide. and i authored a letter that the ranking member, republicans and democrats, signed asking for just that. i'd hate to have to do that legislatively.

i think that's something that -- that the secretary can do and should do and will ask him through you to do just that. until it is a stated priority we're not going to see the changes that we need to see. we're not going to prioritize prevention. we're not going to move from pilot programs to full implementation of necessary interventions. i just believe in that wholeheartedly. and it needs to happen. and if we need to get the veterans advocate community behind that to create the political pressure and will to do that, then so be it. but let's not have to do that. one of the questions i have is whether if -- we'll just use 22 as our baseline statistic, 22 veterans a day taking their lives. if 17 of those veterans are not accessing va care and if we believe if they were to have accessed va care, the outcomes would have been better. dr. mccarthy, is the va ready

today in terms of capacity, number of providers, space, other considerations to see those 17 veterans? >> that's a very thoughtful question. you know, we've tried to do with the 17 is find other ways to have us reach out to them. and so we have the suite of mobile applications, we've worked on helping providers treat them and so forth. space is a challenge. >> let me ask you this, because i was really looking for a yes or no, and it sounds like the answer is no. i won't put words in your mouth, if the answer is, in fact, yes, tell me. but it sounds like the answer is no. what i'd like to know what it will take to be able to see each one of those 17 veterans in terms of resources, in terms of planning, in terms of new facilities, in terms of agreements with community providers to take some of the pressure off the va for what i would call non-core priorities. arthritis is incredibly important to provide care for, so is diabetes, so is the flu. but if there's a community provider who can see veterans

arthritis is incredibly important to provide care for, so is diabetes, so is the flu. but if there's a community provider who can see veterans for those issues so that we can focus our hiring and our resources and our care for as dr. rowe said an eminently preventible condition, suicidal ideaiation and ultimately suicide, we can do that, and we can prevent the loss of life. i can't think of anything more important for the va to do, and so my question for you and through you to the secretary and i think each of us wants to see the answer to this. what will it take to see each of those 17 veterans? it sounds like we'll have an updated number this summer. >> yes. >> the question follows if that

number is 25 and if only 4 of the 25 we want to know what the other 21 are going to do. would you mind providing an anxious of a full, detailed, honest, accurate answer to every member of this committee? >> i'll be happy do my best to get that answer to you, sir. i took it when you asked me the question did we have the capacity internally, and we do not have that capacity internally. when you mentioned community providers, we do have a network of community providers but we're not up to speed with 100% of them in that position. so, yes, we'll take your question, and i promise you, we'll give you the answer to the best of our ability. >> thank you.

i yield back. >> thank you. mr. hulescamp? >> thank you, mr. chairman. mr. o'rourke has done tremendous work bringing the attention of the committee and recognizing the difficulties in his area. i want to follow up a little bit more on the questions that you mentioned and the network of community providers. can you describe how the choice program has worked in terms of mental health care and meeting the needs of rural areas like mine and elsewhere across the country. >> so, let me start with the choice program. i can talk about the community care that was provided and the number of appointments that have been provided by choice. i'm going to speak in somewhat round numbers. but in the -- in fiscal year '13 we had over 16,000 appointments in the community. in fiscal year '14, 24,000. fiscal year '15 we had 31,000 in the community. and over 3.4 thousand through

choice. the choice program has green. this year we have over 18,000 so far and there are a number that haven't yet been attributed to the year that when people were doing the review. so, the choice program is growing. and we're grateful for that, and i know our veterans are. >> and the numbers on choice, do you know which those are based on waiting too long versus distance requirements? >> that, sir, i do not know. i do not know. >> and do you have a general figure on the waiting time for those that -- and how do you calculate that in this particular situation? >> so, our undersecretary has asked us to rethink access and how we talk about wait times. and to do that in a veteran-centric way. he said really the only important measure of wait time is the veteran satisfaction with how quickly they've been seen. and so that is the direction we're moving toward in calculating how we're doing with access. we have an online kind of -- or kiosk means, i'm sorry, in which we'll assess veterans each day as they're in our system. and did they get the care they needed when they felt they needed it. and a similar question, we have -- what we use is the shep survey and other health care systems ask the same question as part of the cap survey, but that

question is was the care available to you when you needed it. and that really is how we need to feel about accessing in a veteran-centric way. we want to be transparent, sir, and we just feel like as we've gone through all the descriptions of create date, desired date, you know, all those -- all those other descriptors, we've managed to confuse a lot of people and really the most important person we want to satisfy is the veteran. and so our measures -- >> in this situation it's certainly not like other items in health care. we're dealing with suicide. >> yes, sir. >> obviously a very serious matter. i'm not saying the others are not, so what is the number? i heard the long description how difficult. if you call and push seven, you're one of the lucky 12 vas you don't have to dial the crisis hotline, how long does it take for you to see a mental health care provider? and do you not have that number, or tell us. >> so, first of all, if you press seven or you call the crisis line, that gets you to

the crisis line where an assessment is made, is this an urgent situation, just as was asked before. if the veteran is in urgent need and the veteran calls or comes to the medical center, our expectation is that that veteran is seen that day. okay. they come to our emergency room, they're seen that day. an urgent need is seen that day. our -- however, if they come to a place like a community-based outpatient clinic and it's, you know, after-hours or something and the clinic is closed, we need to understand urgency there. our expectation is that the medical center, the parent medical center, has an emergency room where that person could be seen. urgent same day. >> but what if you're 200 miles away? >> so, then if you're working through the crisis line the expectation is that the crisis

line assists you with getting the care you need. reaching out either to the medical center or to some -- the suicide prevention coordinators in the medical center to arrange for that care. urgent, the expectation. >> but, again, a little more. these are limited circumstances, but in rural areas i don't think you have the network in my area that you certainly have elsewhere. what do they do? i'm just curious, and maybe it's individual circumstance, each one of these probably obviously is. what do they do, when they are 200 miles away they call the hotline and they say it's an urgent situation. so, what do you do next? >> well, caitlin who has worked the hotline will explain this. >> yeah, certainly. and this happens all the time. the crisis line has received calls from people who were in the middle of lakes, you know, so you get that emergency person immediately to that person.

if the va is 200 miles away they'll immediately go to the closest facility and all of that is coordinated between the crisis line and the local officials. >> local officials. sorry to get into this, but unless the choice program is working well, that -- which in some cases it's not, you're just going to call -- who would you call? >> so, i think we're talking -- we might be talking about a couple of different things. but in terms of an imminent situation, someone says i am feeling suicidal, the veteran crisis line will get them to whoever is available at that moment the closest person, and then they can coordinate that care afterwards. >> and i appreciate -- i'm sorry, mr. chairman. rural areas, this is not just with veterans. where's the network. and i'd be curious in the state of kansas and elsewhere, show me who you would call, because i doubt that you have a network up that you can pick up the phone and say i know who to call out in the middle of western kansas and say we're going to get --

and, again, we're 200, 300 miles away and every other care they're expected to drive until we did the choice program, so if we could have some follow-up discussion in my particular area what do they do. because i'm hearing from veterans, i'm hearing from folks active duty as well, what do they do and the phone's not working. but these emergent situations and long term as well, what do you do after that. >> exactly. >> two months later and there's no -- not much of a network there. >> and that's the crux of suicide prevention. so, i'll be looking forward to the follow-up. >> i apologize, mr. chairman. >> thank you. ms. rice? >> thank you, mr. chairman. i'll direct this question to ms. mccarthy. i've heard from many veterans who straighted from the military with what's called other than an honorable discharge. we all know that. that was their designation. these are the veterans who are often the most difficult to reach out to because depending on the discharge, they are not able to access many -- access many va services like health care, housing or employment help. the va's characterization of discharge process is we all know very messy. it often takes years before a decision is made on whether or not a veteran can have a reclassification so that they are eligible for these benefits. and i want to just take a moment to thank our colleague mike

coffman for introducing the veteran urgent access to mental health care act to ensure that all veterans, regardless of their discharge designation, can accession the care they desperately need before something tragic happens. it seems to me that that's about as big a red flag as you can have for someone who might be -- have suicidal issues, right? because of that designation. so, what i want to know is, what is the va doing specifically to increase outreach to this most vulnerable population of veterans with other than honorable discharges? have you researched that there is a connection between that designation of other than honorable discharge and suicide

or attempted suicides? and i think your ability to kind of improve the characterization of discharge process is limited, because i know it's, you know, it's either air force or the specific wing. but what, if anything, have you done to address this issue? >> so, thanks for the question. let me -- let me start by saying that it is indeed a problem. and we have identified it certainly in partnership with ava, we've been working on trying to come to a solution. that's partly why we wanted to make sure the -- first of all, the mobile apps are all available. there's this 12 suite this whole suite of things and they have

access to the kinds of tools, the use of meditation and coaching for ptsd and online tools which can help them with their symptoms, help them identify them and them help them with the treatments. any vietnam veteran seen i believe before 2004 at the vet center and then all combat veterans are eligible for services at the vet center. there are 80% of the employees there are veterans themselves, and they can actually provide counseling for people, irregardless of the kind of discharge, and they also provide some counseling to active duty military as part of the choice act we were ask to open our doors and -- for a veteran -- for active duty service members with mst and some of them are coming to the vet centers for the care. >> what about the connection

between the designation and suicides or attempted suicides? do you have that number or no? >> i don't have that number. i think a.v.a. has that number. >> there's been a study done that two times more at risk for suicide. this is one piece why a.v.a. has been so focused on this issue. there's a recent report out and others that partnered on the report that estimates 125,000 post-9/11 vets with bad paper, not all of these are going to fall into that category of needing mental health, but certainly some of them will. and for some of these, these are individuals who might have been -- received that discharge status due to symptoms of an undiagnosed mental health illness or injury. and so this is why we are certainly urging passing of the fairness for veterans act but we're also calling for -- we all need to come together. at dod, this is a dod, va, congress and the vsos and msos, there needs to be a comprehensive plan. we've been over the last few years there have been pieces

that have been getting to the solution, but we haven't gotten near to that solution. the other challenge is that many of the community providers out there, many of the community programs, base their eligibility off of the definition and the eligibility requirements at va. so, even those programs that could potentially be helping these individuals aren't available to them. the vet centers are fantastic. our members are constantly holding them up as -- as a top resource, resources they go to, resources they recommend. and one of the things we'd like to see done is an assessment of the vet centers, how they're being used, are there enough of them, are they underutilized, are they overutilized and how can we expand them because if there is that demand there, they certainly are not just for those with bad paper but for families as well. their criteria is much more

broad than the va and they can do a lot more. >> if i can just make a comment. i applaud you. i would imagine how difficult it must be for you to get past what must have been enormous anger and for you to be able to deal with that and be sitting here and be such an advocate. i was at an event last night with an organization called penfed, and they support obviously our veterans, but also last night one of the caregivers for a veteran was given an award, and it was the mother of a service member who was severely wounded in his service. and i think it's time that we, you know, maybe focus on help to caregivers as well. >> absolutely. >> but it is an enormous population that we ask a lot of and you sacrifice an enormous amount, and i thank you very

much. thank you, mr. chairman. >> well, thank you for that. >> thank you very much. mr. coffman? you're recognized. >> thank you, mr. chairman. appreciate the comments of congresswoman rice on this important issue of veterans being discharged under other than honorable conditions and being denied access to mental health care from the va. combat veterans with multiple tours of duty, who i think in a very unfair way, for particularly the united states army to conduct reduction in force through singling out combat veterans who might have some disciplinary issues, oftentimes we believe related to posttramatic stress disorder, and that are discharged without any access to va mental health care is a recipe for problems in and of itself. and so this legislation -- and i know many of the members here, mr. o'rourke, mr. waltz, mr. zeldin and others are co-sponsoring this legislation. but we absolutely need to get

that done. i want to thank iava for really being a catalyst on this very important issue. let me just pivot to -- i have a real concern that we've had testimony before this committee before concerning -- concerning a drug-centric therapy. and a form of treatment, modality of treatment. in fact, we had testimony of veteran suicide, where i think a former service member was given a cocktail of drugs in response to treatment. and then moved, relocated. the prescriptions ran out. was unable to navigate the bureaucracy of vha to get the prescriptions refilled, and given the powerful nature of some of those drugs, took his own life.

and then i think we've had testimony as well -- well, in fact, i was with congressman lamborn in his district in colorado springs where we had testimony from parents of a marine who had served tours of duty i think in iraq and afghanistan. had left the service. went to the va for mental health care. they gave him a very powerful drug that part of the -- part of the directions on the drug were it required constant monitoring. he was not monitored. he subsequently took his life.

and so i just think that this reliance on these very powerful drugs is a shortcut to treatment. by the va. and i think it's costing veteran lives. and i want you to respond to that. >> so, you know, i'm not prepared to talk about individual situations. >> sure. >> but i'd be happy to talk about our expectation. when we had learned about some of these problems with people moving, we've made it really clear the expectation is that the meds continue and that any barriers to that be broken down so that the meds would continue. so, we appreciate that having been brought to our attention, and it is certainly our hope and our expectation that that particular problem is not occurring at this time. as far as treatments go, the evidence-based treatments for ptsd in particular include cognitive behavioral therapy, prolonged exposure therapies, all therapies that do not involve medications. and it's really important that the right kinds of treatments are used. as a provider, a psychiatrist, who has treated veterans with ptsd, i know that often the despair and the frustration and the impatience that you see when you talk to a veteran leads you to think i've got to do something. and i think that leads to people at times making choices about

meds that they might not otherwise make. let me try this. let me try that. you know, there is no single pill that's a cure for -- >> well, a pill to get up in the morning and a pill to go to bed at night and a pill for this and that. >> and that's wrong. >> i think it has an adverse cumulative effect. i think it's been raised by this panel about the vacancies in the va in terms of mental health providers being hired by vha. we had a very good roundtable with the leadership of vha in this room, not that long ago, and one thing that was interesting that was raised in

that was, how difficult it is for somebody who wants a job in the va to navigate, how long it takes to get accepted by the va and how long it takes to get placed by the va and how significant the attrition rate is by those who start the process and those who simply can't afford to finish the process. and so it's been raised that it was a function of compensation. i contend that it's part of this bureaucracy that needs to be cleaned up. mr. chairman, i yield back. >> thank you. mr. waltz, you're recognized. >> thank you, mr. chairman, and thank you to all of you for being here. and to the va, thank you on the -- the clay/hunt bill is near and dear for many in this room, not just those up here but sitting behind you. i appreciate the va not just approaching to fulfill the letter of the law but the firt of the law and for that you should be thanked and i'm grateful. also i think the things that have been spoken by my colleagues talking about veteran health care in a vacuum outside of health care in general is a problem. therein lies an opportunity. we have an opportunity to find

new ways to partner and deliver care and new ways to use best practices to move those things forward. ill will echo what mr. o'rourke, the chairman and the ranking member all said, and if i can add my word to this. it's obvious you have elevated this to the highest level. i think va has to in general. when we see a list of 12 priorities, my suggestion is it better be near the top. that's what my constituents are asking for. in that i'm asking the question, we've been tracking this very closely this legislation and there's no doubt in my mind the willingness to implement is there and it's happening. my question, though, is it seems like the coordination might be something. and, dr. mccarthy, i don't question, i just wonder, and i ask you, do we need to elevate va suicide prevention to the office of the secretary, as we do this, so the coordination is tighter? >> thank you for that question. we are in the process of reorganizing the suicide prevention office and raising it

higher in the organization right now and increasing the number of staff as well as the resources. when we talked about elevating it, at one point we did talk about a separate line item in the budget would effectively elevate it as well. but in any case, what we -- what we very much know is that it needs to report higher in the organization. dod has elevated it to the level of a secretary. i'm not sure that's what we're going to do. dr. caitlin thompson is our suicide prevention coordinator, and we are having her report directly through the undersecretary for health, dr. shulkin, and i think that's an important place given that in that position, she will have the opportunity to reach across the aisle to vba and effectively partner with dod. >> well, i certainly don't want

us to interfere with the organizational structure down to that level but i certainly do want everyone to know that, dr. thompson, i would like you to open up your office door to the secretary on this 21. if that's what it takes to do that that's what we'd like to do. i would segue to the people we are not reaching. you do a wonderful job when we get them in. i think that's what many of the members focused on. "the new york times" focused on clay hunt's unit itself, that unit and the minnesota national guard, clusters. we've got to get better at predicting the clusters. i know it's tough stuff that you're working on. i would ask this, the chairman and the ranking member, all of you look at it from a coordinated broader perspective but there have been several mentions of the groups trying to

get the coordination there team rubicon and jake khan, battle buddy with clay, those folks. i would humbly request that we do something that we bring them in to talk about how they're doing this. getting almost immediate care. that was our vision of the clay hunt. that was the vision of where these groups are at and i know dr. roe brought in the people that operate the tennessee, indiana areas. these people are out there doing it certainly what works for set trains is what works. we have to be evidence based and cost conscience on delivering these but the purpose of the bill was to get that peer to peer out in the community. do you feel that's happening? we mention the names.

i'd like them to be here because we think that model is working. >> we fully agree and are reaching out and partnering with folks at the table here often and in addition with