law in 2014, grading a pathway for some veterans to receive some of their health care through the private sector. there has been a debate on how best to deliver health care to veterans for some time. the last two years have provided some experience to consider as policymakers in washington decide how to proceed going forward. today, our speakers will help us understand the complex system through which veterans receive their care, and how that is changing given the unique needs of veterans. i would like to thank our sponsor for today's events, ascension health. i'm going to turn over the microphone to mark case for a few words. >> welcome. i'm going to be brief. i want to thank you all for coming to this important reaping on important issue -- briefing

on an important issue. we are proud to be a sponsor because the care for our nation's veterans is important. it is this issue that combines veterans issues and health care issues. tois a great issue for us meet in ways that we don't always interact. we have a great panel this morning. ascension is the largest nonprofit health system in the united states and the largest catholic system in the world. we participate in the veterans choice program because we see caring for our nation's veterans, those who have served alongside the v.a. as something that is very central to our mission. we are pleased to participate in the program and are looking forward to what we will learn this morning. thank you all for being here. >> thank you, mark.

if you are following at home on c-span, you are welcome to also follow, and those in the room are welcome to follow and participate in the twitter conversation. htag is veterans health. to poseuse twitter questions to the panelists after each of them speaks. after we go through all of them speaking, we will go to your questions. you will be able to ask questions in several ways. you can post them to twitter. #veteransheal we have toth. provence in the room. our staff will be around to pick those cards up, and i will present them to the panelists.

if you are not with us in the room today, you can find the speakers presentations and other allheces at our website alth.org. i'm going to introduce our panelists today. gallons,have sherman he has served our country in the marines for over a decade. after 9/11, as he was preparing to apply for afghanistan, sherman sustained a cervical spine injury that ended his military career. he has served his fellow veterans through his work at the paralyzed veterans of america. thank you for your service to our country. have -- you have the decade or he -- deputy undersecretary or health. before joining the v.a., he was medicine expert in hiv

at the university of pennsylvania. is ceo oftyre tri-west health alliance which he founded in 1996. kerry farmer is a senior policy researcher for the behavioral and social sciences department at the rand corporation. she includes quality of health care for military service members and veterans as well as treatment and recovery from dramatic brain injury. finally we have the senior vice president and operations chief financial officer for life point health. he oversees operations support and planning department that provide direct assistance to like point hospitals and providers. we will start off first with sherman. i can it over to you. >> thank you.

the clicker here. good afternoon, everyone. these pictures show me at the book ends of my military career. 17-year-old private first class that became the 29-year-old commissioned officer you see on the slide. i did not know at that time much about being a veteran, nor did i care. i did not receive care from a va provider. any information would have been provided by secondhand information or outright ignorance. we have too many in the media and government who share the lack of insight and insist they know best. hopefully we can change that today. here is why.

because this happens. car accidents, training, illnesses, combat. the hazards of military service. this was my car after i was extra grated from the vehicle desk extricated from the vehicle 14 years ago. i was unconscious. 11 days of intensive care until i stabilized. with theirst contact v.a. medical center where i started my rehabilitation journey. it was based on a decision that was my own. my life was in the hands and judgment of others. the same is true for other service members and veterans who have seen war and have found mental and physical hardship. futurell the v.a. of the look like for them, what will change?

will it be better or worse? who will decide? will that decision be based on public outrage and reaction to isolated incidents or political pundits and decision-makers look foot ineadlines and set several va hospital's and talk with veterans? now, a byproduct of the v.a. health care. one of the many that has worked through the system and seen firsthand what needs to improve. i know by expense what makes it unique, a veteran centric system of health care that cannot easily be replicated. there is more work to do. this version of me -- i have access to emergency rooms and urgent care centers when the

v.a. was not readily available. on balance, the providers were all confident and compassionate and responsive to my needs. as i recall much of my relevant medical history while fighting a debilitating fever because my records were not billable. i will be left in a waiting room behind a cast of actors from all parts of society as just another guy in a wheelchair who needed medical care. while still dealing with what failed me, i would drive myself to the nearest drugstore hoping a carried my prescription. more than once, i had to bounce around to several drugstores or wait for the medication to come back into stock. this is what fragmented health taken out like when of the abstract for the veterans it impacts.

let's take a look at who will be affected today. and in the future as the v.a. health care of all. for most, getting dental care and eyeglasses and x-rays, urgent and emergency care in a timely manner is a good thing. let's not underestimate what that means or the men and women in my circumstances or worse. the numbers on the slide are not just statistics. these are veterans whose quality of life is a matter of life and death, in many cases for the rest of their lives. who is a problem for those agreed that the v.a. should retain functionality of specialized services. they say the v.a. can just do what it does best and privatize rest. that will not work, here's why. having a spinal cord injury does not mean i will not get cancer, have a heart attack, develop diabetes, or suffer depression or need was referred to as

tertiary care. veterans access those other services such as oncology, surgery, urology, neurology, and they are closely followed by a specialized care team because of the interdisciplinary framework that is special to the v.a.. that is why you cannot separate. specialized services would erode if tertiary services were remanded entirely to the private sector. with this slide in front of you, we will turn to a discussion on the attributes that make the v.a. health care unique based on my 14 years of expense as a user of that. specialized care that most people -- likely do not know. here is a little bit of education. i would like to start with the ones in the red boxes.

seeknow veterans who emergency medical care in the private sector do not have to pay the expenses provided they provided.st is timely that is not so in the private sector. veterans are reimbursed for their mileage and travel -- unless it is provided by the v.a. or contractor. that is not so in the private sector. seamlesscan receive access to prosthetics and arms the services and support during appointments making it a more veteran centric experience than they can receive anywhere else. that's not so in the private sector. eligible veterans to have a choice through the choice act. that is a good thing because they can seek care through an alternate provider if timely care is not available.

component,at as a not as a replacement. i would like to close with comments from one of the most overlooked aspects of the collaboration between the v.a. and the private sector when discussing health care. title 38 of the united states code, the authority that governs the delivery of the v.a. benefits and health care medical veterans from malpractice rates, and accredited presentation at no cost. what many do not know is that title 38 afforded protection do not follow the veteran who chooses care under the choice act. congress will not have the jurisdiction to compel testimony from private sector ceos whose health care systems have hidden wait lists. maybe we are wrongly assuming it never happens. veterans will have to rely on

the courts for redress if health care goes wrong if they can afford it. if effective collaboration is to happen, this must be addressed. as long as these veterans know that, that is the reality. we have given them not just a choice but an informed choice beyond hoping for the best. if they chose the v.a. for their health care, it needs to be a viable choice. thank you. [applause] >> thank you. we will now turn to the doctor. >> thank you very much. amazing just an firsthand experience of some of the care that is provided in the v.a. just a little about myself, i am a practicing physician within the v.a. when i am not seeing patients as

often as i would like these days, i'm in washington, d.c. one of the key pieces about my journey with the v.a. is that i trained in the v.a. as a medical student in florida and a fellow at the university of pennsylvania at the philadelphia va . 70% of all american doctors at some point interact with the v.a. that is a key point of the system, not only taking care of our veterans but also training the next generation of nurses, doctors, and other health care professionals that will take care of all americans. two sherman's point, the end of the day what we want to see as a vision for the v.a. and health care, is what we call integrated health care system. it includes the v.a. health care providers and clinics as well as leverages expertise from the private sector. unlike many other health care

expertise in the united states that is limited by geographic markets, so if you are starting a clinic, what you actually do is patients come to you. the v.a. is the opposite. we go to where the patients are. our veterans live in every corner of the united states. places, some urban places. they span the entire geography of america. in those circumstances, we cannot have a brick-and-mortar facility in every one of those individual locations. we have to leverage community partnerships, and they are about partnerships, not just purchase of care. partnerships that allows to provide health care to veterans in those areas. we want to build an integrated health care network. i know the alliance has taken on a lot of these various programs and focused on medicare, so

-- a medicarey integratedould be health care that includes the a and community providers. we need both aspects that meets the full spectrum of needs for veteran population. we start with the middle. the v.a. community care is that ongoing transformation since the choice act came about. one year ago we presented a plan to congress to consolidate care. we have multiple ways of reducing care in the community. -- purchasing care in the community. we have been partnering with community providers for decades upon decades. the choice act might have been the spotlight on our ability to purchase care, we purchased way

more care outside of the choice act than we do inside. we have been doing that for years and years. we have great partnerships with academic medical centers. we are able to share clinical knowledge and research and training expertise. this is not new to the v.a., this ability to partner with different providers across the country. they span the spectrum from academic, community providers, federal institutions like dod or indian health services, to your regular mom-and-pop shops across the country. how do we get to this integrated health care network? we need to focus on the veteran. we talked to veterans, visit different facilities, and we mapped the veterans journey through community care. it starts with eligibility. we need to have a clear set of eligibility criteria that makes it easy to understand that what

veterans and community providers and our staff administered. because of these various programs, it creates confusion. veterans benefit that have earned and deserve, it is not clear in the community. we have to be clear about who is eligible and who is not an make it fair and equitable and communicate that. to immunitytes providers. because of the different programs that have different eligibility criteria, are trinity partners sometimes don't know if they are seeing a veteran that can be covered by the v.a. or not. that great problems with payments. wherere are circumstances we are not by law able to provide payment. care, access to community this really has to do with making sure we are able to leverage electronic exchanges of information so that the doctor

knows clearly what veterans they are seeing and the reason for that, and the veteran knows why they are seeing that doctor. care or nation is where the magic is golden nugget. not only for our health care system but are all american medicine. american medicine as we move through value-based payments and integrated networks, this is the thing that folks are trying to figure out. you cannot live in your own institutions anymore. yet the work with other community partners weather for delivering health care or community resources white house and or transportation -- like housing or transportation. we start to address this because of our ability to integrate care in the community and our own health care system. we are to leverage more electronic health care information exchanges, portals

to share medical records seamlessly. the next one is the community care network. who is this network of writers we work with? this gets to the idea of informed choice. we have a broad network of providers. 350,000 providers we work with. we want to make sure the veteran is empowered to make informed decisions about the providers they want to see. this is the same movement that all american medicine is getting too, how do we get our network to report on quality, satisfaction, value so veterans are able to choose a provider that makes sense to them. health care is a personal matter. how do you choose a provider that actually meets their needs? part of it is identifying what we call our preferred providers. we know that our providers in the v.a. by interacting with

veterans understand military cultural competency and some of the unique circumstances and conditions that our population has. in the private sector, they're just really is not enough volume or touch points with veterans to understand all the different nuances. we want our preferred providers to deliver excellent quality and good value, but also have expertise in military cultural competency and be aware of veterans issues. that is a way we can help our veteran population understand issues a provider that meets their needs. next is provider payment. this is critically important especially as being a practicing physician. we view providers as partners. in order to be good partners, we have to pay timely and accurately. this is something that the v.a. continues to work on because of the multiple ways we have of buying care today.

it creates a lot of confusion. one example, when the choice act was passed, the v.a. was required to send out about 9 million cards to individuals. these look like health insurance cards. we have encountered veterans who have taken those cards to a community provider, and the provider worked under the assumption that this veteran was eligible, but on the backend we were not able to pay those clinicians because they did not meet those criteria. we have to have very clear eligibility criteria that is simple. no red tape. make it easy for folks to understand so that the community and the veteran know exactly what is eligible and what is not. and also so we can do our part to make sure we pay timely and accurately. a focus on the customer and customer service. making sure we are able to get information to them in a quick and timely matter -- manner.

that is our journey right now and how we are tackling improved community care. focusing on the veterans and the touch points that are important to them and projects to be able to move the needle in those areas. almost every one of those areas, we need to partner with congress to make sure we make the system less complicated than what it is. when you are trying to run a program that is keeping the veteran in the middle, it makes it hard when there is not one program, there are seven or eight programs. we have to get that one program that makes sense for our population. i wanted to mention a little bit about how we can move towards a high-performing network. this is the concept of the network i just described, internal partners and external partners. this graphic depicts that a little bit. you can see veterans moving from one location to another, including the v.a. and various community partners.

we want to stay where health care is in the future, and what we can do to position us so we are meeting the needs of veterans today and tomorrow. that means evolving from a fee-for-service model to a value-based service model. with all the various demonstration projects, their testing out various models to make sense from the value-based perspective. we want to participate in those. we want to make sure that we are not driven just by volume but more towards value. we need some legislative help in order to be able to do that. better want to leverage monitoring of quality utilization satisfaction and value. we want to be transparent about the care we are delivering in the v.a. and community. right now, we report publicly and a lot of areas markers

related to access and quality and satisfaction. we want to be able to get that same level from community providers that are veterans are participating in. we want to transition to a care model that is personalized and corrugated. we have a medical home model where we have teams that take care of veterans. we need to be able to leverage that same sort of personalized care as veterans go in and out of the v.a.. that will be a unique challenge for us that is also faced by many health care institutions across the country. being able to match veteran with the right level of need, so some veterans might just need a navigator to know where to go, what to bring, and others may need a case manager to help them manage multiple appointments, transportation. so how we get to the needs of the patients and how we get them to the resources and follow their trajectory as they go in and out of the v.a.

we need to leverage better exchange of information. right now, there are a number of different health care providers that use different electronic records. the v8 has been in the business of the hr's for decades. we need to communicate is between different entities. we have innovative ways of doing that by leveraging some of the community health exchanges that are in existence today and moving towards portals that share information. that is a little about the future of the ba in some of the challenges that we face from a legislative standpoint, but also opportunities for us to lead the way in some areas for american medicine. thank you. >> thank you. [applause] >> marilyn, thank you. good afternoon, everybody. thank you for being here. those of you that represent

members of congress, it is a pleasure to serve your constituents. that is part of why you are here. it is a privilege to follow sherman who did a great job of laying out the population that that isndividual responsible for being served by this system. and a great job laying out where the system is today and where it needs to be going going forward. the ask for me was the layout how we get to where we are. what we currently do from a private sector perspective. i will spend a little bit of time talking about the scaling that was involved in where we sit when we look through my end of this lens, and that is responsible for one half of the country to build the integrated delivery system downtown.

representssherman the privilege of us serving the best of the best of this country. people that served this country. i live in phoenix, arizona. in april 2014, we all know what was disclosed in phoenix. legislation and funded it at the same time to give the v.a. money in order to scale internally and by more care downtown. they gave the private sector and the v.a. 90 days to stand this up. when the time the roles were figured out, we had 33 days to go from a blank sheet of paper to. -- two. up.aper to full start we were on the track of what needed to be done and spent a lot of time figuring out the gaps between congress, the v.a.,

and the private sector, and how to close those things. adjustments have to be made. 5%have gone about sending down the track -- 75% down the track of closing those. there is more refinement that needs to be done. massive scale had to be built. placement was key. the greatest challenge was getting people to understand what was enacted both within the v.a. and within congress itself and among the beneficiary population and health care provider community. this was launched quickly. we sit here today a little bit past november 5 of 2014 when this needed to start. over 5 million appointments have now occurred. the network we built has been responsible for 3.2 million of those. how do you go about building a

network? you have to understand the demand curve your we started working with individual v.a. medical centers understanding demand. if you have never fully delivered on demand, you don't understand it. we try to look at that. iss network, the blue area our area of responsibility. we do not have a good sight line of what the demand picture looks like for what needed to be sochased in the community the v.a. would have elasticity it needed. this is what it looks like now. if you go back, that is only 14 of january. this is what it is now. the bottom line of it is very few cases are now returned to the v.a. in our area of responsibility because there is not a provider to see that person when the v.a. is unable to deliver that care rightly. i would like to thank ascension

for being a partner in life point for being part of that network. providers spread across 28 states that in delivering care today. in the first month, we served 2000 people. you can see what the demand curve has look like. v.a. has been buying care in the private sector for a long time. we have a lens on the delivery system, and we are owned by nonprofit plans. they integrate care. that is the core of what they do. you look at this demand curve. we are not at the top of it yet. aret 6000 units of care placed each day from 2000 a month that was done previously. at the beginning of choice, as you start into something like

this, it is chiropractic, but i agree, the low-cost. now it is brain and heart, digestive systems, brain injury, cancer. those things are getting placed in the community. what are the challenges that remain? when i look at this, i still believe we have not entirely sold the access equation. properly map the demand curve. make sure we have the right providers in the network and that we are operating in an integrated way to make sure people have confidence that the providers in the community are the right ones to place their care with. the second one is continued refinement. we went through the various aspects of what is being refined today. the biggest issue at the moment on our side is to make sure that providers understand what it

takes to file a claim properly, and that the process works in a streamlined fashion on our side, and as the v.a. reimburses us for the payment that we make a providers that that full stream works. we have work to do. i was here the start of tri-care when the dod set it up almost 20 years ago. i was in the same role then. dod to 3.5 years for the engineer claims to get it right. the people and the v.a. are incredibly focused in this space. we are making a lot more progress than we made 20 years ago with dod. if you go to a place like rio texas, we just finished a triangulated project there to bring the v.a. together with the hospitals in the community and our company to be able to look at how we get claims rights between all three of us. the average are

dramatically in a short as five weeks. we plan to do that across the country. we have a very inhumane dialogue going on in this country around this issue. this is not about privatizing the v.a. that is not a good idea. we has citizens have invested a lot of money in the architecture and infrastructure of a great system. at the end of the day, this is about resetting the system. that is going to take 10 years to 15 years. unfortunately, folks thought when you pass a bill and fund it, you're done. that is just the down payment on getting started. some of us remember what happened with walter reed. it needed to be reset and reengineered. that took eight years. this is an entire system. it is about making sure that the people who served in combat the

last 10 years that came from every zip code in this country have the ability to go back where they came from and live there and receive care. if you are in a place like sherman's, you may need to go to a place that is right next to the v.a. medical center. the bottom line is the system is not set for that, so this is partially resetting. and making sure eligibility is more streamlined. the last thing i would say to those of you that are staffers, and i was a staffer alone time ago, about 20 years ago when i left capitol hill, in the 60's when we passed medicare and medicaid, we created them as entitlements. the v.a. is not an entitlement. the choice act makes it a virtual entitlement. that is a good thing. it is time to step back and understand whether the v.a. should be the primary pair, or

we should think about as a country about the notion that those who served our country have the right, the first right to an entitlement. a lot of things would end up in a very different place without the case. -- were that the case. that would be a challenge to former colleagues and those that follow me as a staffer. lastly, this is about teamwork. i come from the city of phoenix. that is where the infernal started. billboard wass put up in phoenix. he replaced a billboard that was right outside the v.a. the said the v.a. is lying. thatine months, the staff were driving to work saw that every day they went in. there are people that dishonest that happen to be in the private sector or the public sector, but not everybody is dishonest. the fact of the matter, it was demoralizing.

what this billboard shows that in our places that one as of monday, it takes a team to deliver for those that serve this country, not to replace the v.a., but to give it the elasticity that he needs. 400 providers in phoenix surrounded by 8800 providers in maricopa county of every specialty, giving them the elasticity they need. thank you very much. [applause] thank you, david. not to carry farmer of the rand corporation. >> i'm going to give a little bit of a different perspective from the research side. part of the choice act was a independentof an assessment of veterans health care. we participated in that. i will share some of our findings of the quality of care,

access to care, and we know about quality of care and access to care in the private sector. starting with quality of care. v.a.oked at what the regularly reports, many quality measures. when we compared the v.a.'s performance on this quality measures compared to the private sector, and by this i mean v.a.are, hmos, the performed as well and in many cases that are on these quality measures. turning to the timeliness of care, we also examined the v.a. wait time data. when we think about timeliness, we think about how long it takes to get an appointment. in this case the v.a. measures wait times by how long it is between the preferred date of care, the date that the veteran or the provider would like care to occur and the date it

actually occurs. in our analysis, we found that most veterans received care within two weeks of their preferred date for care. there is a lot of variability in these numbers. in phoenix, it was not two weeks . in other parts of the country, the wait time was much shorter. on average, the wait time for primary care was six days. aspect of the access issue is where do veterans live relative to where their health care is. liveng at where veterans relative to the v.a. sillies, the vast majority live within 40 miles of some facility. this could include a hospital outpatient clinic when you look at more specialized needs, a small proportion of the veteran population lives within the range of a facility that can provide that kind of care.

what does this mean about the v.a. turning to the community to help fill some of those gaps? what do we know about care in the community? whether we know about health care in the u.s.? overall, the u.s. has a ways to go in improving quality of care. this is one of the landmark studies looking at quality of care across the u.s. 50% of allceived recommended care. chronic conditions and acute conditions. there has been a lot of work understanding quality of care. there have been a number of studies examining the quality of care in the u.s., and what we know overall is that the quality of care in the u.s. is variable, and there is room for improvement across all health care conditions.

mentioned military cultural competence. providers in the community who are serving veterans need to understand the particular needs of those veterans, their experiences in the military, and in this study we conducted in 2014, we did a study of behavioral health care providers across the u.s., and less than half regularly asked their patients if they were veterans, and even fewer reported knowing anything about military culture. what we know about the timeliness of care in the private sector? we know very little. it is ethical to compare timeliness of the v.a. care to the private sector. timelinesseasures and friendly, and there is not one standard in how you measure this. sector, between when the patient called and when the appointment occurred, we found in these studies, the wait

times were much longer, so 19 days for primary care appointment in one city and 13 days in another. these also had a range. when you compare that to six days on average and the v.a., it suggests that timeliness may not be resolved by the private sector. finally, when we think about where veterans live relative to the v.a. on that slide i showed earlier, what about where veterans live relative to other providers in their community. this shows veterans who live far from the v.a., more than 40 miles away. among those veterans, 80% live within four miles of a primary -- 40 miles of a primary care provider in their community. when you look at specialized needs, less than half live within the private sector mental health provider.

even fewer live within 40 miles of the private sector neurologist feared this means this is a challenge for rural health care overhaul. this is not particular to the v.a.. for veterans who live far, opening up the opportunity to seek care in the community is not necessarily going to solve this problem because those providers may not exist in their communities either. itking at this overall, suggests that private sector care should, the v.a. care. the v.a. provides care in most cases with high-quality and a timely manner, and the private sector should come in and complement, not substitute. it is important since we know very little about the quality of care for veterans provided in the community and timeliness that is provided in the community to really develop a mechanism for monitoring that care to ensure that both within the v.a. and in the community,

it is high-quality and timely for veterans. >> thank you. [applause] >> before we turn to our final speaker, i would like to invite everybody in the room and watching on c-span that you can participate in the twitter conversation, #veteranshealth. we will open it up to your questions after john speaks. there are three ways to ask russians. you can submit your questions on twitter using the #veteranshealth. you can ask questions from the microphone in the room. in your packets, you have a green card, and you can write your questions there. we will hear from john. you can get your questions ready in the meantime. >> thank you. thank you all for being here. before we start, i would like to recognize david who is the vice

president of government relations here with me today. is here to answer any questions. i would like to start by identifying my point and who we are. it will frame any comments i make from a small nonurban community provider perspective. we will walk through some of the volume indicators of the veterans we are seeing within life point and talk a little bit about what we see as opportunities to expand the provider based within this program. a little bit about life and health, 72 hospital campuses in 22 states. we are nonurban. a leading health care provider in our communities. we are typically the soul health care provider or acute care

provider in our communities. we operate in areas where the closest facility is over 100 miles away. about availability to some of these higher-end services, these are typically the markets we serve. we are not urban. there is not a va hospital near us. in a lot of markets there's not another acute care provider or us. our ability to serve these veterans in our community is very important to us. avid supporter of veterans access choice and accountability act. this has been an emotional issue for our leadership team. a lot of our leadership in our facilities are veterans themselves. they are in small communities know the veterans that live there. this is been important and emotional for them. they have embraced this entirely. it was interesting, we were proud of the work you have done in particular with veterans choice to reach out to their

communities and became a resource for veterans to use to identify whether or not they were eligible. they have embraced it negatively. -- significantly. some volume statistics of the care we provided in 2015. we have provided care for over 15,000 veterans. of those 15,000, 1200 were inpatient. 4600 through emergency rooms. 1600 outpatient surgeries. more than 7100 outpatient procedures and tests in 2015. that is up from 14 and continues to grow. proud.very where can we prove -- improve? there some statistics here that we can compare back to life

point. when we look at days to pay, which is when we get paid for services compared to when we discharge the patient. daysll pairs, it is 54 until we are paid. within our group, it says veterans trust, but it is the p c3 program, it takes 100 days on average to get paid. here's why that is important. for life point, we have a strong balance sheet. we have the resources to basically finance this care. our costs, if we look at medicare rates which are almost the fact of that cost, we are able to bridge that gap between paying for the cost of care that we provided and then being paid 113 days later. if you look at the statistics for local access hospital, their days cash on hand or 69 days.

it's at the hospital, it is over 200. for these small independent hospitals, rural hospitals, that are fairly fragile, they only have 69 days on hand. it is difficult for them when you provide care and you are waiting to get paid at cost where you become almost a financing arm for these patients. i think by reducing that a lot of our sister, independent rural hospitals don't purchase a just because of the cost issue. -- participate just because of the cost issue. that is an area we have looked at a lot within my point. we have seen some of it is provider self-inflicted. there are some ways to mirror medicare. our medicare data they are less than 21. we would welcome the opportunity to work collaboratively and see

how we can get from 113 down to closer to medicare. we believe in the hospitals we work with that would be attractive to them to get into these programs in these small communities. a lot of them simply cannot afford to do that. . -- next slide. there are things that we do well and that we can improve on. i think coming together and figuring out a way to get through some of the prompt pay issues, we believe would bring especially small providers into this network. [applause] >> thank you. now are going to turn to the q and a version of our program.

i would like to throughout -- throw out the first question. we have talked about care in the ba system and the private sector, and i would love for one or more of our panelists to take us back to square one and talk about the choice program that came about in 2014 and help us to understand. who is eligible for this program? how are veterans using it? to what extent are they using it? we have just about everybody using it? what kinds of services are they getting? >> why don't i take that one. the choice program came about approximately two years ago or so. it is a temporary program. i think this is important because it is set to expire august 7 of next year. we are less than 12 months before this program expires.

this is a huge issue because we see the train coming, and we serve more than one million veterans in this program. one million veterans have touched the community through this. this is one of the things that the v.a. is very concerned about because there are a lot of folks that are receiving care through the program. that is one important point. the second is that this program serves a very specific set of eligibility criteria. as i mentioned before, we have seven or eight ways of purchasing care. this is one of them. criteria is very targeted. they can fall into three pockets. one is distance, so it is 40 miles from primary care provider. if you live more than 40 miles from the primary care physician, you are eligible. if you cannot get care within the wait time goals of the department. third is called unusual and

excessive. if there's a mountain range or a lake or stream or very severe weather, we are able to use exceptions. those are the three types of veterans that are eligible. as you imagine, the geographic criteria for the most part is set. we have a stable operation. the wait time criteria alters. an individual may be receiving care in the v.a. for one condition that maybe we cannot provide timely, so they would go out for an upset of care in the community. that requires a lot of care or nation. ofse are the three types criteria. when we talk about the services, they are common. when i think of the top five, we send out a lot of optometry, eyeglasses.

we send out some orthopedic surgery. laboratory a ton of testing. if they're getting an mri, that is done closer to home. laboratory tests. it tends to be more locally available specialties, although mentioning, we are able to get a more robust network where we can refer some of the more congregated procedures. that is a little bit of the next. -- mix. >> what you are seeing on the experience on our end, about 15% of the population is 40 miles. that are are those near ava medical center, and the v.a. medical center does not have the particular service that is those that 35%

could not be seen within 30 days and choose to access their rights. if i could just for those that are staff members, the expiring in august of the program. it is unusual for congress to authorize and appropriate at the same time. it usually does not happen -- blackboxlacks issues. budget rulesonal were suspended in order to get this through. that set the trigger for august 7. without action, the whole program goes away. that is what we were talking about and the notion that it needs to transfer to something else or it needs to be reauthorized from a budgetary perspective. thank you.

let's turn to the audience. we have a question. if you could please identify yourself. >> my name is regina, and i am a doctoral student at george mason. i have a question -- basically a comment and question. with veterans needing more access to care, it would seem possible that the v.a. hospital would allow advanced practitioners to have full practice authority. the veterans access to quality care bill would allow this and help the va hospital accomplish its goals. in do you see utilizing mp's the future? >> that is a great and controversial question. we leverage a lot of nurse practitioners, physician assistants, provider extenders. i am not exactly the right

person to be able to address this specifically, but i will say in general we have veterans that live in every corner of the united states. colleague was demonstrating, in some areas there are not physicians for their is a dearth of those providers. we need to leverage more of our nurse practitioner colleagues and other providers to take care of veterans. i could make a comment as well. outside of any care we provide for veterans, for us being in the small communities, nurse practitioners, physician assistants are an important part of that provider network. we use them very effectively. they provide great care in small communities. it is important. >> i also want to jump in and say that whenever recommendations in the independent assessment was indeed that nurse practitioners

and that the evidence, the research shows there is not a difference in the quality of care between those providers. >> question here. >> i'm dr. pro, primary care physician. , a very quickion question. -- i work for the active-duty military for 12 wha wasive years at thent the best the naval hospital. the military at that time were electronicmake their medical records operable with the v.a. they spent billions of dollars. my understanding was they gave up. they cannot make it happen -- could not make it happen.

how are you planning to make these operable with all community providers that have all kinds of different ehr? obviously it cannot be the way that we try to integrate because that did not work. >> that is a next question. i don't think they have given up quite yet. the point you are describing is really an american medicine issue which is there are health care issues across the country and there is a market for electronic health care records. it is competitive. everyone has different records. we have to think about it differently. we are doing a couple of things that the v.a. that show a lot of promise. number one is leveraging community health exchanges. we are part of about 80 health exchanges across the country. a lot of these are individual communities that get together, the hospital systems that say they will share information, a standard template of data that

they get. we share records with -- we have therans, more than half of million that are participating in these its changes. number two, not everyone will always have the same record. the question is how can you share information between the records? what we have done with our dod partners and transferring that knowledge to the community is having something that is a you are of the records. you can get a view only read of .he records and not alter it with the dod, we have something called a joint viewer that gives us a read-only view of the dod record. it is integrated. it is not like we look at the dod record, the v.a. record, it is integrated. we have these all over the country. we are taking that knowledge and testing it out in a couple of

locations with community providers. we are testing them in the states of new york, north carolina, and washington. we are working with specific community partners and giving them a read-only view. as a practicing doctor if i want to look at the mri or e.g., i could do that through this web-based portal. john, is your system for profit or not-for-profit? >> we are for profit. as a practicing we have severals about the use of other tools such as telemedicine and how the or. is using telemedicine

community-based services provide access to care for rural bets and those with mobility issues, and how can congress help or tomunity-based services encourage this? >> v.a. is at the tip of the sphere when it comes to telehealth. we have a number of telehealth hubs and have been doing various versions of telehealth for a long time. you want to make sure we can in certain areas where you may not be able to have a written mortar building. we're leveraging more and more telehealth, in all kinds of specialties, not only in primary care, but mental health care, dermatology. looking at what other fields have not even traditionally be done. there are a couple of things that could really help v.a. with

being able to share information, especially with community providers, whether they are telehealth or not you there's a couple statutes that prevent v.a. from sharing medical records. these were developed decades ago and they are above and beyond the hipaa requirements. if someone identifies as having -- we are taking a big chunk the population. it is almost a stigmatization that we almost have to get them to sign a special form. our ability tod coordinate care, whether through telehealth or traditional in person venue.

it helps provide higher-quality care that is coordinated. i concur with what the doctor said in terms of taking down those carriers. placed in facilities rings -- colorado springs in patients for mental health because the mid--- military hospital did not have a unit. we required the sharing. sharing of that information is really important, making sure the patient encounter is proper that mightg the gaps otherwise exist. starting this week we will be standing of a series of pilots marketsl roll out to and expand from there that will put us behind the tip of the

sphere, which is v.a. health.do tele-mental will help give them more supply and also do psychotherapy on the same backbone that will allow us to test out in urban and rural toas how we jointly want make sure people are taking care of a leveraged supply in the private sector when it's not available in the v.a. making sure that providers are understanding of who a veteran is, then we select carefully he plays people with his really important. we put a million dollars into a nonprofit that is construct the teaching information that will be made available to providers all over this country as it relates to understanding the veteran, and also the evidence-based therapy training has v.a. and dod

specialized in and make that available from a distance perspective with a coaching apparatus on the back end that we designed in conference with v.a. and dod. that information will be available free of charge to providers all over this country .ho want to step >> telemedicine and home-based care and first multiplayer. veterans whoy benefit from it. i want her same provider and that i mesh well. it's not a panacea. i'm always hearing from nurses to talk about -- you can see it

on the screen, but it's not the as appreciating how bad it is when you are there and see it in. i see my doctor once a year when i do my annual exams in person. we don't want to see it as the end-all, be-all for all types of care. >> we have a question at the mic. >> thank you for being here today. that as them to me , it also provides us with an opportunity to introduce changes to the program and is a veteran who remembers what it was like living 98 miles away from a civility before veteran's came in, i certainly can relate to the benefits and

challenges that we face. i suspect you would recommend title 38 protection. was gap in the choice act mentioned here, for those of us -- it'salized services, going to cost money. it will. if you truly intend to open access to all veterans, it has in if i can'tt get an appointment time, maybe there is an injury expert in the private sector who can do a test or take care of an acute issue and then i will follow up, that

was a gaping hole. i would never be eligible. -- that i would need in hope be one area where i we could take a look at that. i really appreciate that question, we laid out our vision of what do we want choice to evolve. we have to not just extended , as david wase describing, this came very rapidly, was implemented rapidly . in partnership with congress we were obtained -- change the law four times as already. i will list a couple. number one is this primary payer issue. in some stir -- circumstances, nonservice connected veteran, we have to rely on their other health insurance.

as they have to pay their co-pays, that it articles, their premiums, and no other program in v.a. work that way. it's exposing them to some financial costs they never had before, and a lot of them were very upset about that, not thoseg they had to pay specific portions. two, we need to be able to really work better with community partners, especially in rural areaqs. -- areas. right now the choice law those specific limits v.a. and medicare. we need to be able to have some flexibility to partner with providers and pay them a higher rate. a lot of times we definitely you have some issues in the payment area. tohave got to be able to get flexibility and payment and move towards those value-based payment.

i mentioned a couple of the other things of being able to coordinate care better, allowing us to share information. the penultimate thing is we have to evolve this program. we have invested a lot of infrastructure. it would have to evolve. i don't think it should be completely scrapped and start from new because we will go through the same growing pains that we did two years ago. how do we continue to take what is there and turn it into a program that makes sense for veterans, community partners, and the v.a.? i imagine some of our other panelists have ideas about what this to happen with program. >> the issue around the 40 miles in primary care facility is an issue that we deal with all the time. a veteran will not qualify under the choice award because there may be v.a. center within 40 miles.

not have a surgical suite, some high-end diagnostic work. a veteran that is three miles away from one of our facilities where we'll have an mri or surgical suite, they need .urgery we have been able to work through those issues. it is one off negotiations with the veterans administration. that has been an issue. a lot of these veterans that that theyare of need have, they are not able to utilize it because of the 40 mile rule. >> just to comment on that -- this is one of those things we have to be aware of what it .ould mean sometimes we talk about 40 miles .rom primary care doctor a lot of folks have also done those modeling. it definitely would have a large impact impact apart from

that. two sherman's point earlier, we need to be careful about referral patterns, and in order to provide high-quality care of veteransce-connected and tbi patients, if we cannot provide wraparound is, because a lot of us are being delivered somewhere else, outside the to to gainbecomes hard competency and recruit doctors in those areas. it is worthwhile looking at and figuring out how we can get stability for investments and need to be seen. in some circumstances, one mile is to our or two days late is too long. what that will actually do is to track some of the folks that will be using it or want to use it.

in some circumstances, one mile i would concur with the that thinking about completely open access is probably not the right place to end up. we've invested in a lot of infrastructure, and making that structure stronger, and making sure it's got sufficient supply to meet the need will be for the last 15 years, we've deployed people from every zip code in this country. for the last 15 years, we've deployed people from every many of them want to go back home and they don't want to have to displace where they are. they may want to take a error or two off, and they have the right to do that. they have a benefit they are.

making sure they have access to care in a reasonable distance, i agreewe would all appear makes sense. how do we draw the parameters right. from its then prospective -- perspective, congress needs to decide, how does it want to deal with the responsibility that .omes with the tale of conflict there's a lot of money that is paid in travel. there's a lot of money that is getg paid when someone is what they need on a timely basis. when they are really sick, it's more expensive. get what they need on a timelyi woun types of things, you want to be in a v.a. facility. want to be in a top-notch academic facility, regardless of were you live in a state

look forward on our and doing whatever needs to be done to make sure we asked -- properly to make that work great. >> in some way or needs to be a bigger conversation about what is the obligation to veterans. wethe decision is that continue as is and the v.a. has an annual budget that submitted two years in a dance, every time there's an increase in demand beyond what was expected or projected, they're going to be access problems. they're are going to have to be decisions to stay within the budget. this is going to be true for community care as well. the ability to constrain those costs, particularly if you increase eligibility, will be .ifficult to >> we've had several questioners claims know how to get

paid faster. what is the answer? just a softball question. will let others comments. this is probably one of the things i spend a big chunk of my day on, actually as a doctor. when one of our partners delivers care, they deserve to be paid on time and accurately. what we are realizing as we do is there are a number of root cause issues here that have to be addressed to make sure we are able to timely pay our providers. one gets back to the eligibility . when we have 6, 7, 8 different programs, all with different eligibility criteria, if you don't match them up exact rewrite and you are providing care for a non-service-connected condition or a veteran who lives

38 miles, not what he miles, we don't have the authority as the department to cover the bill. that is really unfortunate the criteria -- there are so many of them and they vary as many times a veteran receives care that isn't authorized or we don't have the ability to pay for that. do we get to a simple set of eligibility criteria that is very clear to our patients and to our providers, that there isn't any ambiguity. in medicare it is pretty simple. you turn a certain age, you have a card, you are good to go in or if you have a private health insurance plan, they know what benefits are available. we need to be able to get to that level of clarity. have 7, 8continue to different programs that are operating differently, it will be hard for our patients and providers to know that. we have to make some adjustments to the laws. , probably theay

biggest area that i get reminders about complaints are er care. we propose a fix to this in our isn to consolidate care and v.a. is the primary payer. in other circumstances we are the payer of last results -- last resort. oflaw and statute we pay 70% the medicare rate. when we talked to a lot of doctors and sit down with them we we are examining a.r.'s, did pay, and it is considered payment in full. they still carry a chunk of that on their accounts receivable. that is something we would not be able to pay until we get the law changed. that's where i see a lot of consternation around this unauthorized care where we had to figure out if they are service-connected or not and we

are not allowed to pay the full medicare price by statute. we proposed making v.a. the does require some investment and some funds to do that. good are able to get this criteria, iron out some of the kinks in the er system, then will allow us to automate more and more and more and leverage community partners. it is very hard to automate like medicare does, when you actually have to go to the medical record , which is what you have to do it er care, to determine the -- you can't really do that by computer. hasto see if the veteran what he has seen for a knee injury, and is that he injury

connected. i don't want our team to continue doing that all the time. drag.es a long time we on the backend can then automated and pay it. this is a great opportunity for us for progress. however, we need help. at v.a. we cannot meet the standard we want to meet the artist doing it by ourselves. we need help from our legal and congressional colleagues. >> as an entity now responsible for paying for two point million appointments, we don't collect when we have this right yet. about three months and it became

obvious that the dod has never paid lames properly. dr., you had walked into a scenario. he didn't create it. some of the history in this space that dates back a long time if that the v.a. was painted claims market by market by market by market. that's not a very effective way to do it. it's hard to get the core competency. end of the day, they have consolidated what that looks like. that was a very needed change. they took all the claims and they aim them in one direction on the government side. the second thing is, when you're in an institution, you have file properly. when you are a provider, you have to i'll properly. no one wants to be in a place or claims get denied or where they are slow. at the end of the day we have to find another provider to the next veteran. that is not in anybody's interest.

playing timely and accurately is in everyone's interest. work, done a lot of the at the start of tri-care to help the dod get this right and get it right across the system to make it the fastest and most accurate payer of those types of programs, you also have to pay one way. the care moves directly from the v.a. to the community, they pay one way. if it moves through choice, it goes down a different lane. so now imagine being the billing office trying to your out, which place to send this? rather than it all goes through one consolidated pipe. that is something that needs to get fixed. we did a project in texas. team, myself,s

the members of congress from that area and hospitals in that area. it's an area where a lot of care moves downtown because they have a community-based outpatient clinic and the rest of the works done downtown have been that way for a long time. some of the hospitals of those four had a 50% denial rate on their claims. they did not know how to file accurately. within five weeks, together we dropped it to 10%. that takes their historical pattern payments and changes it dramatically. we all own a part of this responsibility. it starts with the provider filing accurately. then it goes to us making sure we have processes that work and it is streamlined and consistent. as an actor that spent time in the dod space back 20 years ago,

the same issues existed then and they got fixed. to those that are in the provider community that are leaning forward, thanks for doing that. and thanks for hanging in there. what i've seen with my sleeves rolled up is that the v.a. team -- there's no separation with what we are trying to accomplish . the way this works is we pay the bill. and in the v.a. pays us. we all wanted to work right and together i think we will be able to hear what those pieces are, as the doctor said, that need to be changed. there are some other pragmatic components that have to be paid as well to make it work right at the end of the day. we are picking a couple markets to test things in together and then we will take what we learn and apply that to the rest of enterprise. >> i would extend on david's comments. i do agree with the one

pipeline, as a provider you are used to dealing with intricate payer rules. medicare is a great example. providers, we know what those rules are. other systems we can incorporate into our processes. we know when a medicare recipient comes in for a certain task, what the diagnosis has to be in how to deal with it in real time. all the private payers have their own rules. but they are consistent rules of that payer and we can develop systems and processes to deal with them. the extent that there's one les,line, one set of ru arias the providers can develop their processes and systems around be very beneficial. we have time for one or two

more actions. as we are winding down, i would love to ask you to fill out the blue evaluation warming your elders before you leave us today. let's turn now to a question at the mic. >> hello. i wanted to ask you about the commission on care report that was put out a few months ago. i wanted to get your response to two of those recommendations. one was for an independent advisory board and one was to eliminate the time and distance requirements for the choice program. the first idea is controversial and possibly unconstitutional. so nice to see hypothetically what would be the impact of either of those two changes. >> i will comment more on the latter. kind ofy and president put up our response to the commission and in the

president's response to the commission they actually call out our plan to consolidate care as an alternative approach to some of the recommendations and the commission. most of those recommendations are -- our mom and apple pie. you believe our plan that lays out really getting all these different programs into one, coming up with an eligibility criteria that make sense, and also allow some like civility so when a fake doctor i'm seeing a patient in front of me can make a decision about, you would better be served at this institution, the community is important to getting to that single way of a referral, , anding that i network getting to timely payments wrapped around customer service. all of that is really laid out in our consolidation plans,

which is what the department and administration is putting forward. in their it also lays out what we need to do that, what are the specific legislative changes for wired, what is the budget required to do that. i think that is a good starting point where we hope to get to. i will comment on the second recommendation. just looking at the numbers, there's 21 million veterans in the united states. 9 million are enrolled in v.a. 6 million youth v.a. health care in a given year. most veterans enrolled in v.a. health care also have some other choice of health insurance. they might have tri-care, they have other source. and they choose whether to use v.a. health care or their other source of insurance based on a

number of factors, one of which is cost and access, things like that. care topen up purchase the whole veteran population, when you will see is this giant increase in demand. some of these 3 million veterans who are enrolled in v.a. care and using the a health care will start using v.a. health care because now they can go to their local doctor and be able to pay for it, and they probably are not going to face a co-pay because it is through their v.a. benefit, they are not facing a co-pay. the choice of seeing your same doctor, v.a. will pay for it, no co-pay. you go through your private insurance. just the number of people using v.a. health care will increase. that is one thing to consider and the cost of that will be quite significant. of the big picture question of thinking about, do we maintain our health care

system as it is, do we transition to more of a private sector model, you can't really have both with full open access to either. people choose to use private-sector v.a. care, fewer people will be using the v.a. health care facilities. a lot of you are working on health care and you lee understand that as volume decreases, the plenty of care decreases. there is a certain tipping point at which it is not sensible or reasonable to maintain facilities. as v.a. ladies close, it furthers the move into the private sector. that decision from my perspective really needs to be a thought out decision. it needs to be decided and not just something that happens as a death spiral of v.a. facilities hosing because of movement into the private sector. >> if i can follow up -- you said that so eloquently. sometimes think about

privatizing the v.a. and giving everyone a card, as a clinician again, what's missing there is care coordination. when you think about medicare and the way that program works, for the most part it is like a reimbursement system. .ou handle your own care and then the government pays the bill. what's missing from a clinical do you help how folks navigate a very complicated american health care system and making sure their needs are met. i think the greater extent that there is just people doing it on their own, well it might work for a small segment of the population, for many folks it doesn't work. that is important, to think about it from the clinical perspective. do we want to have a coordinated system or do we want everybody to do it by themselves?

>> thank you. do you have a question? go ahead. >> thank you. my question is about what's going on in technology spaces as far as companies like apple and other app development companies that are giving patients the opportunity to be in control of their own medical data. has the v.a. considered partnering with apple or other innovative technology companies in silicon valley that will allow veterans to have their own medical data with them so when they go to visit providers, they can have a dialogue based on the information that they have. >> yes. button?heard of blue blue button is exactly that. it's an easy way to be able to download an electric -- electronic version of your entire health record.

and so, we actually have an entire digital service that leverages folks from such as silicon valley that are thinking of creative ways that we can partner and continue to exchange information. >> you said blue button? >> that's right. also an was pleasantly surprised when i accessed it is not only can you talk to your doctors, your prescription meds, you can get your medical records -- format and also military records. when you have to file a claim or advise somebody to file a claim for a certain message, the first thing we do is get them to sign up blue button. it works wonderfully. >> we have reached the end of our time. a few thank you. . please fill out your blue

evaluation form. i would like to thank supporters for today's reefing and i would like to thank our panelists for a very informed conversation and thank you to all of you for being her today. thank you. and marilyn, thank you.

>> you can watch this entire panel discussion online. we will have the entire event in our video library at c-span.org. roll call is questioning whether donald trump plagiarized a joke he used. joke was about accusations of mr. trump/plagiarizing parts of her convention speech the

summer. cartoon wasll published in july. here's the joke donald trump told at the al smith dinner, followed by one from hillary clinton. >> the president told me to stop whining. but i really have to say, the media is even more by this year than ever before. he won the proof? michelle obama gives a speech. and everyone loves it, it's fantastic. they think she's absolutely great. gives the exact and people get on her case. and i don't get it, i don't know why.

and it wasn't her fault. stand up, melania. it wasn't her fault. she took a lot of abuse. [applause] clinton: there are a lot of friendly faces in this room, people i've been privileged to know and work with. i just want to put you all in a basket of adorables. [laughter] and you look so good in your taxes, or as i refer to them, formal pantsuits. because this is a friendly dinner for such a great cause, donald if any time you don't like what i'm saying, feel free to stand up and shout "wrong" while i'm talking. it's amazing, i'm up here after donald and i didn't think he would be ok with a peaceful transition of power. [laughter]

donald, after listening to your speech, i will also enjoy listening to mike pence deny that you ever gave it. [laughter] i've had the privilege of being at the al smith dinner's in years past. and i always enjoy it. but remember, if you're not happy with the way it comes out, it must be rigged. and it's always a special treat ar me to be back in new york, city that i love and which i think truly embodies the best of america. don't you think? [applause] people look at the statue of liberty and they see a proud symbol of our history as a nation of immigrants. a beacon of hope for around the

world. donald looks at the statue of sees a 4.d navy if she loses the torch and tablet and changes her -- maybe if she loses the torch and tablet and changes her hair. do you know what would be a good number for a woman? 45. [applause] but i digress. now, i'm going to try my best tonight. but i understand i am not known for my sense of humor. that's why it does take a village to write these jokes. people say, and i hear them. i'm boring compared to donald. but i'm not boring at all. in fact, i'm the life of every party i attended, and i've been to three.

the archbishop of new york set between the nominees at dinner last night in the hill reporting he revealed what donald trump told hillary clinton during the charity dinner and that the candidates had several touching moments that were not caught on camera. the cardinal says mr. trump told mrs. clinton she is a tough, talented and, and mrs. clinton according to the cardinal returned the compliment, saying whatever happens, they need to work together after the election. both nominees back on the campaign trail today. secretary clinton in cleveland, ohio, live over on sees them to c-span2 4:30. how the next president might handle those issues. we will hear from the director of coalitions for jeb bush's presidential campaign and also from a former aide to president

bill clinton. on election day, november 8, the nation decides our next president and which party controls the house and in it. how the next president might handle those issues. -- c-span for coverage of the presidential race. and follow key house and senate -- c-span for coverage of the presidential .aces c-span, where history unfolds daily. if you missed any of the presidential debate, go to desktop,g using your phone, or tablet. on our debate page you can watch the entire debate choosing between the split screen or switch camera options. you can go to specific questions and answers from the debate, finding the content you want quickly and easily. c-span.org on your desktop,

phone, or tablet, for the presidential debate. the candidates in the ohio u.s. senate race in it for another debate last night hosted by the city club of cleveland. the republican incumbent leads his challenger by 2-1 in the polls. the degraded supreme court nominees, gun violence, and the u.s. role fighting isis. this comes to us courtesy of wv the wewss well as cleveland and wcpo in cincinnati. >> the issues that matter to you. race for the u.s. senate sponsored by the city club of cleveland. wews news cleveland and wcpo

.leveland >> i'm karen kasler. 5 inam anchor at news cleveland. welcome to the final debate between rob portman and ted strickland. this debate is sponsored by the .ity club of cleveland the rules have been agreed to by the campaign. , we welcome those watching on abc stations as well as those tuning into ohio public radio or television stations. and of course, to those here in our studio audience.

karen and i will ask the candidates questions. the second half, the candidates will respond to questions from the audience. one of those questions will come from twitter. if you like the submitted question, then use the #city club. candidates will have 90 seconds andespond to each question the candidate originally asked each question will have an additional three seconds for rebuttal. the questions have not been shared with the campaign. the audience here in the studio agreed to remain silent so we can focus on what the candidates are saying. we welcome you to applaud at this moment as we welcome the candidates. strickland.and ted [applause]

we are now going to have opening remarks. candidates, a reminder you will each have two minutes for your opening statements. the order was agreed to by both candidates and we begin with sen. portman:. >> it's good to be back in cleveland, believe land. first the cavs and now the indians. you will hear about the real contrast tonight between the two of us. i have been an independent voice for ohio. i'm proud that 45 of my bills have been signed into law. one is a very important issue, the heroin and prescription drug epidemic. it has torn families apart and devastated communities. a comprehensive addiction and recovery act will begin to turn the tide of that terrible epidemic.

whenve mom and a her addict to needs help. i'm running for the many workers in ohio who are feeling the middle-class squeeze. taken a lead on things like worker when addict to needs help. retraining. that level langfield for ohio -- playingludes field for ohio workers includes steel workers begin to fight back. i'm fighting for the 70 new workers right here in cleveland, ohio who have a new job because of our legislation that enables them to win their trade case. i'm proud of the fact that i've been endorsed by every major city newspaper in ohio that is endorsed. the cleveland plain dealer said i reached across the aisle and worked with republicans and democrats to achieve results for cleveland. they also said they did not

think ted strickland could be effective in the u.s. senate. i think they are right, he was not effective as a congressman, as governor. 350,000 jobs were lost. 90,000 jobs were lost in cleveland. when voters turned him out of office, he blamed cleveland. he said, cleveland's biggest cleveland.,000 jobs were i think cleveland's biggest enemy is governor ted strickland's policies. now governor strickland, you have two minutes for your opening remarks. >> it's great to be here in the city of champions. i grew up in a family that had a lot of struggles, but we survived because we loved and we cared for each other. cleveland. i thinkyou lost our first home a hard, our second two times. when i was five, our third home burned to the ground. dad was a steelworker. my mom raised nine kids and i

was in my family to go to college. i learned at a very early age the one bad break can lead to real hardship. that's why i've spent my life as a minister, psychologist, congressman, and as your governor, fighting for working people. that is who i will fight for in the senate. then there is the rob portman story. wealth, power, and privilege. a man who pretends to be nonpartisan. but he's always there when mitch mcconnell and the washington power brokers need him. spending his time and our tax dollars fighting president obama every step of the way. he said the auto rescue was a lousy deal for ohio. he has voted to keep us from curving gun violence. always opposeds

president obama. he voted against president obama 92% of the time. even stood with donald trump after donald trump said that the president was not a citizen grade when you hear independence and bipartisanship, remember this. he is the great pretender. >> you're going to start her first question with you tonight. this has been an unusual election, with a survey of millennials by the university of massachusetts finding they would rather have a lottery determine the winner then to vote for either hillary clinton or donald trump, and a quinnipiac poll released this week found most voters feel neither trump nor clinton is fit to be president. in light of these polls, how do you rationalize supporting your party's candidate for president?

>> there are big differences between hillary clinton and .onald trump donald trump is unfit to be president. he has spent years say that president obama. he has disabled people in a prisoners of war and gold star family you call a -- when he was in no doll is not be president. .iller is a great experience is you are secretary of state to our problems. secretary clinton working with barack obama and bernie sanders -- a education. lesstion is a you make than a year, your child can go to a public college or university tuition free.

that includes about 80% of the people in ohio. think of and not having to worry about whether it college. senator cornyn will support that kind of approach. is not taking the right kind of attitude towards ohio's. he poses ohio's students to refinance their student debt at a lower interest rate. he's tried to cut millions of grants.out of hell -- pell grants. when he's had to choose between ohio students and the banks, he chooses the banks. >> sen. portman: we know it took you a while to withdraw your support from donald trump. i would like to get your take on the fact that millennials grant. h 18 to 34, isn't it a said commentary that that age group sees the candidates as neither one of them being fit to be president? >> i do think it's sad.

if they couldce look up to their presidential candidate. i do think that in this campaign we have seen things said and done that are discouraging. i have stood up, and i have consistently stood up when i thought something was said that was wrong. my opponent hasn't done that. i believe the words matter. words matter so much that i took the extraordinary step not to be able to support my republican nominee for president. when hillary clinton called half of donald trump supporters deplorable, said they were racist, he didd .ot stand up words really matter when there are words. this is the campaign between ted strickland and me. you will hear my opponent continually talked about the presidentialwords really mattere are words. this is the campaign between ted strickland campaign. he wishes he was running against barack obama.

this is what he said during this campaign. he's the one who has used the word rape in an offensive way, somehow to connect rape to charter schools. he said when justice scalia died , it was cause to celebrate. and he did so for political purposes. he celebrated the death of anthony scalia. he came to cleveland during the fortuneon and sent out cookies to asian-americans around ohio and never apologized for it, as a political tactic. my opponent can defend donald trump all he wants, but he stood with and by donald trump after donald trump spent years saying that barack obama was not a citizen. he stood by donald trump and he called women -- when he called women pigs and worse, when he mocked a disabled person.

it wasn't until it was in his political calculation to try to disassociate himself that at the last minute, shortly before this election, he said, i can't vote for donald trump. senator portman, my first question is to you. your colleague promised this week that senate republicans would be united against any supreme court nominee that would putinton forward if she were elected president. issuing a statement saying he would thoroughly examine the record of any supreme court nominee. it is been said the senate has the constitutional obligation to a supremensent of court nominee. regardless of who is elected, would you push for a fair hearing process for a nominee to the court or join the account to block a nominee? >> a fair hearing process. i believe that's what i've done.

there are many of barack obama's nominees who i have found were not all aside -- qualified who i could not support. many i did support. i look at each one on the merits, and that's what we have to do. i don't agree we should automatically block nominees. we should be working together to figure out how to solve problems and ensure we get the best people to serve on the court for a lifetime appointment, that we are finding the best people to serve in the executive branch. when the democrats took back the senate, they took away their 60 vote margin. it could be a mistake for republicans to do that. i disagree with a lot of my colleagues on that. we should vote on the merits. i will look at justices as to whether they are faithful to the constitution, whether they will legislate from the bench, and what their qualifications and backgrounds are.

mr. portman claims that he is independent and bipartisan. he wasn't bipartisan when he came -- when it came to guns. he voted against an amendment that would disallow suspected terrorists from buying guns. he wasn't bipartisan when he came to the bipartisan bill on immigration. perhaps the most egregious acts he has taken has been against judge garland. i'm going to read back the words he just uttered. he said, i don't agree that we block automatically nominee. for months, he has blocked judge garland. he said this man should not have a hearing or get a vote. he has disrespect -- disrespected the president and failed to carry out his constitutional obligation. he has not done his job for 4-4 splitd we have a

on that court. he needs to give us an answer. every newspaper in the state has criticized you for this. and yet you refuse to allow the president's nominee to get a hearing and a vote. you've got some answering to do to the people of ohio. you are not acting in a bipartisan manner. you are acting in a very hyper partisan manner when it comes to the supreme court. be independent, claimed to be bipartisan. on this very serious issue he has not been bipartisan. >> you have 30 seconds to respond. >> i did answer your question, unlike governor strickland. i have voted for barack obama's nominees when i thought they were qualified to that's the record. i wrote haves that become law. this means barack obama signed

those bills. by definition they were bipartisan. get through the house, get signed into law. is a dysfunctional place these days. one reason i'm running for people ini meet washington who know how to do that. it is something that you see less and less in washington. we need to figure out how to work together people in washington who know how to do that. it is something that you as repd democrats to solve big problems. >> thank you. >> there is no denying the growing problem across the country and also here in the state of ohio. last year analone average of eight people a day die from overdoses. many related to opioids like heroine and sentinel to the epidemic is taking a toll on communities who are struggling to cope with the emergency calls overdoses and handle the number of addicts needing treatment. is this an issue that should be handled at the community level,

or is there a role for the federal government? forhere certainly is a role the federal government and you are right in describing the problem, it is a scourge. people are dying needlessly, in part because we don't have adequate treatment available for people who are seeking treatment. i know something about this. i just lost a very close relative to oxycontin overdose a few months ago. it was a sad and a tragic event. a beautiful young man who should not have died. but the fact is that i was aware of this when i was governor and i started the prescription drug task force when i was governor. because so many of these addictions begin as a prescription use and then people get addicted and they don't -- no longer have the prescription or it's too costly so they go to the streets and they find heroin and other substitutes. communities need help. and i applaud my opponent for calling attention to this issue.