Transcripts For CSPAN2 Key Capitol Hill Hearings 20240622

Find seats and we will try to get started here. My name is ed howard. I am with the alliance for Health Reform. I want to welcome you on behalf of the board of directors. I want to welcome you to the program on health and housing with an emphasis on the relationship between medicaid policy at the Community Level at the state level and the federal level as well. This is actually a first in a threepart series and we will explore the intersection of social policy over the next couple months. In october, i believe its october 9, you will be looking at how well Health Services correlate with nonmedical home and unity based services. Then in december we will examine some of the emerging issues in connection between health and incarceration, which is is a growing area of concern and activity. There is a connection between health and various determinants and we will look at the strength of that connection during this briefing and the subsequent ones in the theory. You may have seen yesterday the new york city mayor bellagio announced a milliondollar program to connect more Homeless People with Mental Health care. I think just another sign of growing activity at every level to connect the dots that link Better Health and better housing. I hope that will bring a lot of light on that topic. Our discussion will center on how housing stability affects Health Outcomes and healthcare costs. They will look at the role in addressing this program and how much flexibility there is in federal policy to allow states and communities to meld those together. We want to look at what the obstacles might be. What are the biggest obstacles. We are pleased very much to acknowledge the centime corporation. One of americas largest private insurers. They operate in two dozen states. Before we get to the program let me do a little bit of housekeeping. In your packets there is Important Information including speaker biography one page materials and the Powerpoint Presentation in hard copy so you can follow along. There will be a recording of this briefing available on the website on monday followed by a transcript a few days later along with all of the materials in your kit and links to more materials we think would be helpful to you. At the appropriate time you can ask our Panel Questions by filling out one of the green cards in your packet or you can come to the microphones there is one on either side of the room. You can use the health and housing to tweet us questions and if youre watching on cspan to want to ask a question, you can also tweet a question. We will be keeping an eye on that and having them brought to the panel to respond. And at the end of the briefing there is a blue evaluation form in your packet that i would very much appreciate your filling out so we can improve these briefings and target them to the needs of the folks who come and need the guidance. So, enough of that. That. Lets hear from our very wellinformed panelists. We gave them in adequate introductions and ill do it so i wont disrupt the flow of the discussion as we go along. He is the director of policy at the National Healthcare for the Homeless Council. He is also on the healthcare counsel for marilyn. He has a perspective on how to connect and address these problems. Why its important and the opportunities from the state federal and local levels to address it. Then we will hear from the Senior Advisor for housing and services and she will explain the current activities and describe how her agency and others are collaborating health and housing issues. Gretchen will be next. She is director of colorados department of Public Policy and financing and that is colorados medicaid and chip programs. She is going to tell us about the bridge and what gets in the way of those efforts. Our final panelists is a family physician and she is founder of a phoenix nonprofit that brings private and public sectors together to help those experiencing homelessness. They will describe the Innovative Housing model and what gets in the way of this approach. So weve arrived to the part of the program that also has some substance to it. Heres barbara. I really appreciate so many people being here today. I think it really is important about the growing awareness of how healthcare is changing the country and in particular the impact that housing has on health status. The National Healthcare for the Homeless Council represent many Healthcare Facilities and the Homeless Individuals they serve. Over 1 million patients are being seen in these facilities each year. The lack of housing is really an issue not only for the Health Centers but the larger Healthcare System that we are looking to change. One one of the things that might not be intuitive is how housing affects health care. Back in the 80s the institute of medicine did a study looking at that very impact and they found three major relationships. Poor health causes homelessness. Typically what we would see as a spiral of people who had an illness, were unable unable to work and when youre unable to work and you get fired or laid off and you can no longer bring in money. You cant make rent or mortgage so you move in with family and friends and that doesnt work out so you go to a shelter or live on the street. You also hear that homelessness causes poor health. Living on the street or in a shelter is stressful and you are exposed to other illnesses. Without getting hospitalization or Emergency Care that tends to be very high. High blood blood pressure, Mental Health issues alcoholism depression all tend to develop. If you didnt have them before you tend to develop them afterward or they get exasperated. You also think about how lack of housing complicates treatment. We are putting billions of dollars into our Healthcare Industry every year. 2 trillion. None of that funding works well. Nothing that we do as Healthcare Providers works well when someone is living on the seat. Street. Every time we turn someone to a 90 Day Treatment Program it is only to discharge them to the street we have complicated and probably compromise the treatment we just invested. When we discharge from hospital to the street the wound care that we just paid for is now compromise. These are the things that are really bundled up together in health and housing. We need to appreciate how we can rectify that through housing. One of of the things we are seeing, as again we represent the doctors in nurses and addiction counselors and the workforce that goes beyond caring for these patients, and what we see, not surprisingly, is very high rates of acute and communicable diseases. Respiratory illnesses, infections from cuts that you cant keep clean diabetics on the street, the rate in which we replace medication is astronomical because of the rate they are stolen. When you cant keep your medication safe or refrigerated its hard to maintain compliance with your healthcare. How many times as anybody here gone to the doctor and had a prescription given to them that may cause them to visit the bathroom more often . Thats just not possible. No need for show hands. [laughter] thats just not possible when Public Places dont allow homeless to use the public restroom. We have local ordinances increasingly that criminalize that activity so really what we see as Healthcare Providers, our client come in and say i didnt take that medication because otherwise id get arrested or i was afraid of getting arrested or i didnt have any place to go or made meds were stolen or my needles were stolen or its not safe for me to have needles. This is what we hear. We see when we look at the literature it shows people who are homeless get diseases at three to six times the rate everyone else does. Theres still asthma and diabetes and hypertension and high cholesterol and Heart Disease that everybody else has but it still in higher rates. We see a lot of intensive needs and we see both extremes of use of the Healthcare System. We are getting a lot of attention in the frequent user of very high end user were putting a lot of money into a small number of people that we need to stabilize, but we also see people who are living on the outskirts of our society who avoid our Healthcare System that have intensive needs, usually in the Mental Health and Substance Abuse treatment area. How is it that were reaching those people were very fragile and in need of care . Will look at our hospital systems, they are really stressed. They really get it when you are a hospital and you have no safe discharge option for a client that is ready for discharge. It is illegal to discharge to the street but as with anything else we get discharged for rest and recuperation. What do you do for someone who doesnt have any place to go . These are these are the real issue that local Healthcare Systems are facing. What can we do to provide safe and ethical treatment for people question what we see a lot of people wear when they are ill, its difficult to get back out of homelessness. Working on housing and getting a job, if youre fighting an addiction or Mental Health and not in treatment, its very hard to get out of the shelter or off the street. Just one example of in a healthcares situation, people who are homeless have disproportionate high rates of every disease you can imagine. That brings us to support of housing. When we think about what is Supportive Housing, its typically helpful to think about in terms of a traditional model that emphasizes recovery first. Traditionally, in our communities, we required people to get clean and sober. Weve required them to enter into treatment and be successful with that before we get them into a housing unit. Is everyone follows the rules and you continue to follow the rules then maybe one day you can be in independent housing. While while that certainly works for some it doesnt work for people have really serious Healthcare System. Its hard to get clean when youre living on the street. The Supportive Housing slips that model. Its not not timelimited. Its the same lease as anybody in the community. Frankly any one of us can go home tonight and have a drink and its perfectly all right to do in our home. It needs to be an opportunity as well. We need to work with people where they are in the stabilizing unit of housing so weve got that stability. So people have a place for have a place for the medication, they have a place to put an appointment card and keep track of them. Our outreach people people cant find people when theyre shifting around on the street and encampments change a lot. We need to think about how are we supporting housing in this way. A wide range of teambased services is really the key to making this work. When you combine this biz untrans the ability of housing with Healthcare Services, we can can help people be stable in their housing. This is mainstream right now for seniors and people with disabilities. My grandmother has meals delivered to her peerage and have in care help to help her bathe and keep the house clean. All of these things im taking for granted. Speaking about extending that into this population so we are supporting the housing and the services that people need really isnt keeping up with that same theme. I want to talk about our relapses part of recovery. These are things we need to expect. Recovery in Mental Health and addiction doesnt look like black and white and yes and no. It looks like a struggle. When we have we have people who are in zero tolerance housing, even that one slip up advertises your housing and you could be back on the street. Its really important that we are able to work with people and adJust Services if they need that. Again. Again theres no requirement for sobriety and the services are voluntary, but what we have find found his people are very excited when they get into a unit that now so many things were possible that didnt seem possible before. We been evaluating the effects in the peerreviewed literature for about 25 years and consistently, what we find is that housing improves health and it improves Health Outcome and lowers the total cost of healthcare. I think this is really where we need to be in rethinking housing because we are so focused on cost right now, understandably so. We need to think about where is it we can be making a partnership. You can read the slide here. There are consistent findings over all of these issues but again you really want to focus on how is it bringing these two sectors together is really bringing us the things that we need. There is a lot of opportunities at both the federal, state and local level. All of of your states are working on studies to end homelessness and improve health. Were looking at greater determinants of health. One thing that is important in d. C. To remember is we need federal support for the housing piece that goes along to making this work. My colleagues here well talk a lot about what they are seeing in their sectors but again the cuts that are required by sequestration if we dont have the Housing Support to put people in, no amount of our Healthcare Services are going to make this work well. We need these to come together. Another thing i would really recommend are the take away points, for all of you who are health staffers and those of you who are housing staffers, get to know each other because you have a lot in common. A lot of times we are not working together at the federal level like we are asking them to do at the local level. That would. That would be a lot of things i would recommend. What we are doing at the local level is to try to bridge that gap. We are in a rapidly changing environment including medicaid but the system as a whole is changing. We are focused on outcomes and cost we also need to be focused on Vulnerable People and getting them what they need. Nothing works well as a Healthcare Provider if theyre living on the street. We really want to focus on housing as a healthcare intervention. My colleagues will talk about how hard they focus on building this bridge from housing to health is an illustration of how we are trying to Work Together to make this model work and achieve the outcomes we are looking to achieve. I want to point out, my colleague matt warfield, he can take your car to get back to you if you are looking interested in looking into this further. We we really appreciate you being here. Thank you barbara. I am jennifer. I like to joke that means i am the one person that knows the difference between medicare and medicaid every day. You know what im talking about, dont you . My background, actually i spent the first ten years in my career in managed care. Largely medicaid and medicare managed care. It was in that work that i was first brought to the table to consider the relationship between homelessness and health in the impact that the board of housing would have on both Health Outcomes and spending. I have been doing that ever cents for the last 18 years. I want to assure you that there is an unprecedented level of collaboration happening today between hud and hhs. Not just because of my job but because it really is the case. Hud is trying to talk with medicaid almost every day. Were talking to folks at many different organizations. Were no it feels that housing and healthcare are miles apart and no ones talking, but i want to promise you, in this administration, there is an unprecedented level of collaboration. There is a simple fact about how we invest in housing federally that a lot of people dont know because you operate in a world of mandatory budgets. Federal Housing Assistance is not an entitlement. When someone becomes eligible for medicaid or medicare, they get it. If you fill out an application for housing, you get in line. When we asked congress to invest in more affordable or Supportive Housing they worry about the renewal burden. The fact that this increases our total budget in future years something i like to say keeping people in their homes. The conundrum is today, hud pays for a lot of services and housing that medicaid could pay for medicaid has a lot of financial incentives for there to be a lot more affordable, accessible and Supportive Housing and the budget environment is such that were not doing what we know works and not doing anything at the scale that matches the need. That is that is why im excited to be here with you today because your interest in housing could help create the consensus that we need to make the investment that will matter. Thanks for being here and thanks for allowing me to be on this incredible panel. I want to talk about how this plays out in three areas, aging, disability and homelessness. Americans are living longer and the age of 81 will test our commitment between the relationship of housing and health. The ages and equalizer we will be more likely to live alone have chronic Health Issues, less mobility and we grow poorer. Studies project that the number of older households eligible for rental assistance will increase by 2. 6 Million People between 2011 and 2030. Today at hud we provide rental assistance for 1. 2 million seniors. That is one out of every three seniors who has become eligible for it. That means we would need 900,000 more subsidized Housing Units by 2030 just to keep up with one in three people to need getting it. We have not made significant new investment for seniors for some time. I think about where you live today or where your grandparents live. Less than one half of 1 of existing housing is currently assessable to someone who uses a wheelchair. Only 5 is livable for someone who has mobility impairments and only 40 of it is modifiable. Most americans is not designed for them to age in their existing place imagine 20 Million People who cant return to their home and cant afford where they live. Where will they go . How do we have a strategy for aging in place of people will not be able to afford or navigate the place they call home today . The Health Care System, i would argue, has a huge stake in meeting those needs of aging america yet there is not consensus this is something the federal government should be making. A lot of the work has been focused on disability. There is section 811. 811 forces 811 forces partnership between state housing and state medicaid in some places like colorado it doesnt happen together. They create integrated housing where medicaid provides Homebased Services in a unit that has deep subsidies. We have two rounds of funding 35 states now have this money. The last run we founded funded 4500 units. Thats a drop in the bucket but at least we have made some investment. The Healthcare System, i would argue has a huge stake in creating more integrated Housing Options for individuals with disabilities who would otherwise be in an institutional setting. There is not consensus this is an investment the federal government should make each year. I came to washington to help with chronic homelessness. I appreciate barbara covering all the chronic arguments. I want to add a couple things. First, the president s budget request last year and this year have included investments to create a sufficient supply of Supportive Housing to end chronic homelessness in america. In 2016 he requested 255 million to hundred 55 million to create 25500 Additional Units of Supportive Housing but leverage the creation of many more. So Supportive Housing is proven to help homelessness people. It improves health and reduces er visits. The Healthcare System, i would argue, has a huge stake in our creating a sufficient supply of Supportive Housing to end homelessness in america. Yet there is not consensus that this is an investment the federal government should be making. Second we are learning something in the work that we are doing with the veterans affairs. Here there has been confessing this consensus. We have had a one third reduction in homelessness between 2010 and 2013 and we are on a path to end their homelessness. Imagine if we could get this aligned with medicaid to repeat this with individuals with disabilities who have lived on our streets and in our shelters for years. My my focus has been to work with cns to find ways we can better align housing and medicaid. Im really thrilled with the Housing Related Services report they just published. There there is a link to it in the documents and all of the information you have in your packet. Im increasingly meeting state medicaid directors who understand that if they are going to achieve the goals of Health Reform bend the curve they will need to deal with housing and homelessness and they have a new best friend who is a house. This new document brings clarity to something that was pretty unclear. If housing is over here and health care is over here there is a a whole lot in the middle. What cannot medicaid do to pay for for whom and when . If medicaid were were paying for all the services in support of housing that it can pay for, we would have Better Health outcomes for seniors individuals with disabilities and we could end chronic homelessness. I believe if medicaid became a major player in Supportive Housing we could build the consensus needed to make the level of investments necessary to help seniors age in a home they can navigate and afford. Individuals with disabilities who have a right to to live in an integrated setting have more choices of where to live and there would be more Housing Available because they value and service partnership. Let me finish right started. The conundrum is hud pays for a lot of services in housing that medicaid could pay for. Medicaid has a lot of financial incentive for there to be a lot more affordable accessible and Supportive Housing and the budget environment is such that were not going to do what we know works and were not doing anything at scale. That is why i am excited to be here. Your interest in housing your understanding of the relationship between housing and health, your advocacy for Supportive Housing for older americans, individuals with disabilities, including folks with disabilities living on the street, could help create the consensus we need to make the investments we need to make the investments that will matter. Thank you. Thank you jennifer. Before we we go on, if i can, lets clarify you are talking about the kind of services that medicaid could pay for in Supportive Housing. I wonder if if you could be a little more explicit and say a couple words about what is stopping that from happening now. For example, in our Homeless Assistance Programs we spent over 400 million per year on services. We only need 265 million to create more Supportive Housing to end chronic homelessness but were spending 400 million Million Dollars a year on services. Thats everything for things medicaid cant pay for but a lot of that is exactly the type of and reach, engagement, assistance that is described in the new housing related bulletin. The the biggest barrier is that states dont know what will be approved and what to ask for, everybody is afraid that what we are saying is medicaid should pay for housing. Thats not what were saying. Were saying medicaid should pay for health and these services that we are doing naturally now keep grandma out of the nursing home or keep someone not of an institution, we just need to extend that. Were also paying for services for Service Coordinators in our senior housing, we pay for Service Corps nadirs and Public Housing and a lot of that Service Coordination is really Health System navigation and wellness activity so we dont have an ambulance pulling up every night and we can keep people in their homes longer. Okay, very good. Letsxd turn to gretchen from colorado. Thank you all for inviting colorado to participate in this very interesting conversation. As jennifer mention, colorado is working very diligently on this issue and its a privilege to be able to share with you some of the things we are doing. First i would like to provide a little context. Everything we do within our State Government at this point in time is really driven by our governors platform for health. That is the state of health. Our very bold goal is to be the Healthiest State in the nation. We take that goal very seriously not only because we have a great place to leave live, but we have Health Disparity in our community that are holding us back. We are we are working very hard to move those forward. It really is around this interconnected nature of health for our economic growth, social conditions for Health Care System to work more effectively than it does today, to help healthier people and to create a healthier bid business environment. We believe when we look at those things holistically we are able to put the right Services Support and finances in place. If anyone anyone is familiar with the triple aim, the best care for the best value and that is our translation of that very important concept. That is a commitment to starting with prevention and wellness, which is a lot of what we talk about when we talk about the issues were discussing today. The nature of the Healthcare System needing Health Insurance most of time to access the services you need and making sure we have the capacity within our Healthcare System to meet the needs of the residents of colorado. We invest a lot of money in across the nation in our Healthcare System and we have some opportunities to get better value for the dollars we invest. Some of that requires Infrastructure Investments things like healthcare capacity, primary primary care medical homes, having integrated care between various types of healthcare so we dont have one person with one body going to three different places to get their healthcare needs met. It is our highlevel, holistic view of colorado and how were looking to move our agenda forward. We did expand medicaid in colorado. One of those buckets, as you remember, is a coverage remember, is a coverage and capacity area of focus. Prior to september, or in september 2013, prior to the first day of enrollment in the Affordable Care act we had many residents and now we are up to 1. 2 million covered by medicaid. You can see in the breakdown there is a diversity of a diversity of populations we cover. This is housing conversation has really been accelerated by this expansion. Colorado did some statebased activity and expanded early for those living at 10 of the federal Poverty Level or last. Let me remind you, that is 11,000 a year in income. We expanded to 10 of poverty or last. Prior to the full expansion of poverty or last. Prior to the full expansion of the Affordable Care act and we built on that as we moved into january 1, 2014. It was an important step for us to understand the needs of both of those primarily Homeless Individuals. Understand how to engage with them and support them and getting access to coverage. We wanted to begin to understand what their healthcare needs would be and other kinds of services they would need. Our expansion has been an important piece of our work. Coupled with that expansion has been discussion about permanent support of housing. When our Current Governor was mayor of the city of denver he had a very important platform around homelessness and has continued on into our state based administration. A lot lot of that focus has been around Supportive Housing which is a trend you will notice across the three comments so far. That really has required us to look at the capacity of our housing system. How can we identify and mobilize resources . Colorado is a very, very nice place to live. I have lived there almost all of my life and it is very expensive place to live two. Given that housing is one of those issues that is directly impacted by the other components of the marketplace that are around media income and other things, its really a challenge challenge at times in a very expensive environment. Colorado has one of the hottest real estate markets in the nation at this point in time, to figure figure out how Affordable Housing can be made available. This dual focus of both a Health Platform and a housing platform platform has really set us up very well to look at how we can begin to expand the relationship between these two areas. Health and housing has been an important piece of what weve been working on. We are involved in some of these discussions which means how can we be sure were using those investments appropriately so things are being paid for in a way that makes sense and other housing related expenses can be leveraged in the same way. We engaged in a study and i wanted to talk a little bit about the findings from that. We looked at fiscal year 13, 14 which begins at the First Six Months of the full expansion of medicaid. When we looked at our data there was about 37 enrollees reported homelessness during the year. 24,000 reported thousand reported it during the entire year and the rest of them had talked about being homeless at least some point. I think that is an important piece to call out that when we think of homelessness just like we think about coverage, its a point in time piece for many people. That could be a and of time in your life where youre homeless homeless in a period of time where you have coverage. That may not be how you exist in the world throughout the year. Its important to look at that variance in peoples lives. When we didnt and analysis on the spend for the services for those people it was about 160 million. Through this exercise we began to break down those expenses. Weve been talking a lot about money and id like to believe that what we can recognize about that number is those people were very, very ill. They probably didnt feel very good. I think its important for us to recognize that we have an opportunity to not only potentially save resources if we do this work better, but also help people feel better and help people have a better existence as they move through the world. This is a very important piece that we are looking at both from a budget perspective and from an Overall Health perspective. When we want to be the Healthiest State in the nation, thats for everybody. For everybody. Its a really important balance to look at the spend and the experience that people have. As we hear about these new opportunities, the clarity that came out in june of this year its really a chance for us to have more clarity as we work to see what can we do to bridge between health and housing to not only address these individuals but more permanent structures in place overall. To do that these services can also exist in silos at the State Government level. We have started a cross agency group and they meet twice a week. Some of the basic work that we have had to accomplish is just clarifying language. All bureaucratic programs have their own speak and use acronyms that only we understand so you have to step back and figure out what all of those letters mean. Its been an important clarification of language. We also have to recognize that if its taking us some time to learn how to interact with each other in the 64 counties across the state of colorado, there is obviously going to be some confusion and opportunity for better education. Thats where we are focusing our energy now. Helping all of our providers both on the housing side and the healthcare side, understand what are the opportunities to be working together. How can we begin to break alignment to the funding and synergy. We are all looking at the new waivers and theres a new document out relating to waivers and Substance Abuse. That is a piece of the conversation we havent highlighted but an important piece of how those services can be delivered. Lastly, some of the technology pieces, we have a Homeless Management Information system and a medical Management Information system and as our state is going through a procurement of those we are looking to see if theres opportunity to have connection between those since we are now at a time where technology can help us if we let it. Lastly i would conclude that again, ill circle back that the people who are the hardest at these efforts we are talking about and learning about what the experience of those living in Affordable Housing and their healthcare experiences. One of the most heartbreaking thing is the lack of dignity they felt they were afforded from the Healthcare System. It was a gift that we had a chance to be there but if they were just smarter they could figure out how to navigate are very complicated Healthcare System that i myself challenge to navigate at time. It doesnt cost us any Additional Resources to have respect and dignity for those folks. It is important that we think three visas but there are some things we can do to help improve their health and Mental Wellbeing and all of our society and communities with just some recognition that these are hard issues and the folks that are in the middle of them need some support and respect as we work to resolve them. Thank you gretchen. Now on to doctor osullivan. Im very happy to be here today. I speak from another additional perspective. I am a family physician and i have cared for and exclusively Homeless Population. Is that better, can you hear me . Four and exclusively Homeless Population since 1996. So, i experience every day in trying to give good patient care the trickledown effect of policy and of spending decisions in the lives of my patient and how our ability to make good policy and spending decision influences Health Outcome of very real people. I come from arizona. I am going to speak to you about our situation which, as all of our environments are, is somewhat unique. Arizona is a Medicaid Expansion state. I am happy to say. There is still is still legal challenge pending in the courts. We have other successes that i would like to tell you about. One is that arizona decreased chronic homelessness by 15 between 2013 and 2014. On a note which i experience personally we began in the phoenix area which is a very large and sprawling county with a Homeless Population of approximately 17000. I started a prophet called circle the city and we did that as a community, as a grassroot effort to bring people together to meet the incredible need of those who were too sick too frail to be on our streets and in our shelter. In 2012 we open a new a new facility in the phoenix area. The name for this service is medical respite. The respite word word is somewhat confusing, its recuperative care. You could think of it as Bridge Housing with a very intensive medical support. This has been a crucial part of our ability to provide the sickest, the frail list and the most vulnerable. Another good piece that has happened is that the number of Supportive Housing units is growing. 1600 Housing Units were funded with individuals with a serious mentally ill designation by the continuum of care who funded the rental subsidies and medical medicaid, through a regional public and private initiative that was united way bringing partners together. Another 1000 units were targeted to chronically Homeless Individuals in that county. However, the challenge, we still have a Supportive Housing need and face challenges. We think think it would take about 1000 more units to end chronic homelessness in that county. Our arizona medicaid plan covers a comprehensive bundle of services. The flipside of that is that in Supportive Housing those services are only available to persons with a sears Mental Illness designation. Our nonprofits participated in a Pilot Project with one of the local large medical centers. Frequent users of systems engagement is an acronym of the corporation for Supportive Housing, a tremendous active wonderful partner in trying to get Supportive Housing available to us. In this Pilot Project, we engaged the most frequent, most expensive homeless utilizers of care. We engaged, we offered the services of our medical Respite Center and able to stabilize assess and then quickly move to Supportive Housing. The vouchers were donated by several agencies in the community. That Pilot Project realized a 73 reduction in emergency room visit and a 74 reduction in inpatient utilization. After patients are placed in permanent Supportive Housing the diagnosis is homelessness. These these are patients that we took care of through the pilot program. They didnt have just one chronic disease. Some had to, most had three four or five. That doesnt take into account the acute problem of Heart Failure exacerbation, diabetic, the crises for what people cycle in and out of emergency room. Why do people cycle in and out of Emergency Care . In our our population these are reasons we probably believe and as you can see, the next one on there is that the primary care system might not be responsive to the population issues or the multiple issues that barbara talked about earlier that are simply the recurring phenomenon of being homeless and living on our streets. So i would like to show you, just briefly, one case study of a patient a patient who was in our pilot. We call him mr. 280. He was well was well known to the Phoenix Fire Department because he hit 911 all the time for transport to local hospitals. We think he had 280 visits. With the hospital we worked with he had been to the emergency room 192 times between 2007 and 2013. We engaged him brought him to the Respite Center for three weeks and then we discharged him to permanent Supportive Housing. This is mr. 280s hospital bill. Page. Page one, page two, page three page four, page five page six, page eight page nine and page ten. During that time of he had 192 visits 92 visits to the Emergency Department but not one inpatient admission. I can tell you when we actually engaged him, we found out he was living almost in the hospital parking. 358,000 in charges at one hospital. This is a graph of his hospitalization visits during that time. As you can see there are three places in 12 and 13 when he wasnt in the emergency room for the month and we can show you three mugshots that correspond to those months. So since being housed, he has been to the emergency room twice. Both were appropriate visits. He has has never been admitted to the hospital. He is stably housed and has remained stable he housed over that time. He is receiving care in the Traumatic Brain Injury Clinic at our local neurologic inst. , he has his food handlers car and he is employed parttime at a local restaurant. So what are our challenges . I think you have heard the talk of care coordination, and we love it when we can get someone in the permanent Supportive Housing to have the opportunity and im going to get that diabetic in housing. Im not going to get him healed if hes in a shelter or under a bridge. We need to coordinate the services we provide. We havent exactly figured out who is responsibility that will be. Thats thats another one of those issues where we have to Work Together. We have to prioritize the support in terms of medical need. I think if youve not seen the work done in boston by how the people are dying on our streets we have good data to show that persons with chronic illnesses who are medically vulnerable will not survive and yet our system, our Electronic Systems our silos, if you will, we have to learn how to cross them to prioritize those limited Supportive Housing resources we have to the person who needs them the most. One thing we are really interested in is developing new and innovated models for delivering primary health care efficiently in Supportive Housing. Once we get people there how do we deliver the care in the most efficient way possible . Do we take the services to them . Do we we provide the transportation and the followup to get the fix right . All of those are possibilities. We know that its important to place people immediately. Theyll get sick, for one thing. The second thing is if we can locate the people that need the housing, we need to try to put them there. Id like to put in a plug for medical respite care for the homeless and the growing of these programs at pivotal points where patients who are too ill sometimes for direct placement without the stabilization that ill this can use medical respite for Bridge Housing. My recommendations, housing is healthcare. If we could increase availability of those prominent Supportive Housing units, we need the vouchers and we need the services. Anything we can do to solidify our states to cover those array of services in permanent Supportive Housing, medicaid is wonderful. Medicaid alone cant do it. We need the support from our Mental Health providers. We need hud. We need housing. When we can get those Wraparound Services those positive outcomes that people think arent possible, im here to tell you, are possible. Thank you. Thank you. Thats terrific. Thank you sister adele. We are now at a point where we would love to hear your questions at one of the microphones with the green card that you can fill out and hold up and someone will bring forward or you can tweet it and we will go from there. Let me just start with sister adele if i can. Can you talk, and i would welcome other panelists to chime in, about the kinds of money which pockets were you able to pick to put together what looks like an incredibly impressive array of housing with services that have allowed you to make such progress . So as far as the housing is concerned, through our continuum of care, also to our partnership with the united way we were able to put together some funds from the state department of housing, from a couple of the cities and metropolitan area and from phil philanthropy. Those are the vouchers. The health care folks in the room may be confused by the term continuum of care. I just want to jump in. The Homeless Assistance Program is delivered in communities through loose Community Collaboration that we call communities of care. Thats confusing and i wish we had Something Else since were not even advocating for a continuum model of care anymore. What she is saying is she had money for what would run assistance and Capital Development cost through the hud Homeless Assistant Program which is exactly the same place in the budget that we are trying to get the funding to do the Additional Units exactly like youre saying you need so you can and chronic homeland homelessness. Just just a little plug for that. Okay, thank you for that observation. If you would identify yourself and keep the question as brief as you can we would very much appreciate it. Thank you what experience do any of you have with those who have gone on medicaid as a result of experiencing a Natural Disaster and losing the housing they had before . I would love to talk about what i have observed down in new orleans. Its timely with the anniversary of Hurricane Katrina and rita. One of the things, its tragic and the number of people who lost their homes was devastating. What happened to that community was devastating but what they did in the rebuild is amazing. Because there was a lot of flexible Disaster Recovery money, they got low Income Housing tax credits which is the biggest producer of capital dollars for more Affordable Housing and thats Disaster Recovery money. They got hud money housing choice vouchers, rental assistance and homelessness rental assistance all as Disaster Recovery money. The amazing thing they did is they use the Community Development grant to pay for services while they created Supportive Housing using a log of tax credit. They use the housing choice vouchers to deeply subsidize those units for people experiencing homelessness while they built a medicaid system that would pay for the services and support of housing and become the triage process for identifying people who had that vulnerability and need in the housing. I say that even in a state where the governor has chosen to not expand medicaid, but its shows whats possible when medicaid and housing are used strategically together. I hope that reflects on what you are asking. Okay, very good. I should call attention to whats on the screen and that is an Incentive Program of ours, along with our Incentive Team to get you to fill out the blue evaluation form. If you do in sufficient numbers, that we reach a 50 Participation Rate in this exercise, the alliant alliance will make a contribution to the community of hope here in town which actually deals with some of these programs and problems that weve been discussing including homelessness and healthcare on ground here in d. C. Dont leave without filling out your evaluation form and making sure the person next to you fills out their evaluation form as well. The institute of social medicine and community health, this this panel is a great example of social medicine and yet i am not hearing a focus on standards of care that we would expect all hospitals and Healthcare Providers to be aware of. This mr. 280 that sister osullivan introduced us to do me is an example of how hospitals take advantage of the Medicaid Program to extract as much money as they can from it rather than identify the sources of this mans need and make recommendations for addressing them whether through the resources of the hospital or the resources of the generic community. I think that the colorado story is interesting because they want to be the Healthiest State. That means not just the Healthiest State for Homeless People but the healthiest date for all people. Where are the recommendations on how the Healthcare System should be integrated into this social determinants of health with housing being an example here . Shouldnt we require, through Regulatory Authority standards of health when Healthcare Providers identify to be forced to identify the social causes of the problems they are expected to treat. I think this this is a great opportunity to raise those issues so we can have some Generic Solutions and not just to be proud of reducing homelessness for a certain segment of the population. Ill start with this. I completely agree and appreciate your passion behind this issue. I think what we are trying to do is get our Healthcare System to the place that you have just described. That is not just for special populations, that is for all of us. So, what were all looking so, what were all looking for is an outcome driven, how are we as individual human beings, and on our communities getting health are here . How can we demonstrate that but the resources of our Healthcare System behind that . When i say system, i mean an i mean an actual integrated system that has informed with it and resources to deliver the kind of care we envisioned in the presentations here. We are trying to build the capacity to get there and a lot of that has to do with the partnerships that been described among people who are in charge of the social determinants and not limited to housing but good education, good jobs, good nutrition. I think when we talk about investments in housing and talking about the partnerships we need to have, its informed by recognizing this man does not have housing and thats whats contributing to his 280 emergency room visits. How does does the Hospital Partner with the Healthcare Provider in the community as well as housing coordinator. That means identifying the Housing Resources that are woefully insufficient in many areas of the country. I applaud what you are discussing as well only have to get there. That includes federal investments as well. Does that address your question . It addresses it beautifully. I would add one of the ways we are seeing movement on this issue is, 1i think i think theres been a broader recognition of the impact on someones ability to achieve their Health Potential and in addition through our medicaid Delivery System for our physical Health Services that are through a Collaborative Health structure with regional entities and Key Performance indicators that they get Additional Resources to achieve. Some of those we picked very strategically to begin and those are a 30 day readmission to the hospital, inappropriate utilization and the cost of high cost imaging. The many bills that mr. 280 had experience. We do that for a couple reasons, thats high cost and nobody likes to have imaging done if its not needed. It had both components it. Some recognize there may be underlying factors and these peoples lives that with attention we can meet these Key Performance indicators. Those are transforming over time. We now have wellchild visits and postpartum visits. When we been talking about homelessness and a general homelessness in a general term and certainly there are homeless families as well we believe all of those indicators can help continue to broaden the focus on the entire individual or family need beyond just the single engagement with the Healthcare System. If i can follow up with the point that i did not make which is important, this population largely was seen in eligible for medicaid up until the point of the medical care act extending medicaid. This population wasnt wasnt even part of the system. We are now they were eligible but probably not enrolled because of how hard it was to be enrolled. Rights only if you had a disability but the vast majority were single, nondisabled elderly adults who are not eligible for that or any other Health Insurance. This is the first time we are able to get them into a system to look at their healthcare needs. Actually, for mr. 280, that was mr. 280, that was before Medicaid Expansion so he had no insurance. Very good point. Yes go ahead. Hello, my name is eleanor with the Infectious Diseases society and hiv association. Thank thank you to the panelists. This is has been wonderful. When barbara and sister adele were talking about housing, she kept referring to permanent Supportive Housing. The question is is are there mechanism in place to support individuals phaseout so they can sustain their own housing and also sustain their own medical needs . Are there any metrics put in place to be able to determine when somebody is able to phase out of Supportive Housing if it is meant for them to phaseout of question marks. Im im happy to start at one. A couple things, in the world of homelessness, the term of Supportive Housing was really created to distinguish it from what had been the paradigm of the day which was transitional housing. What it meant is it was a time limited program and you could stay as long as you needed to. The the ability to stay in the same home and not have a clock ticking is actually supportive of recovery. The stress associated with knowing that you have to have your act together at a certain period of time and you need to be able to go someplace else is counterproductive to having longterm stability and working on longterm goals. It is designed obviously we hear stories every day of people who dont need it anymore and who get a job and want to move out and make the Space Available for someone else. I think thats also where our agent portfolio is a great example. We do Supportive Housing for the elderly and the expectation is that when grandma turns 90 she should be able to move someplace else. The concept that housing is your home and its where you live, that is the idea of home and that is the idea, the lifechanging event from hopelessness in the street to hope in a future that happens when somebody moves into a home of their own. When they move out of an institution and into a community and an apartment of their own. We want to support that ability in support people being able to move off that assistance whenever thats possible. When we are working with people were aging and peoples who have severe disability and have been living on the street for long time i think we need to understand they will need support for a long time and perhaps the rest of their life. We see people every day and im sure sister a doubt you see this every day, people get off the street and we afford them the dignity of dying in their own home instead of dying on the street because they came to you. Those things happen very frequently. Ive heard a couple themes that are slightly different among the speakers and maybe there could be a little bit of dialogue. One was medicaid should pay for housing. One was they dont need to pay for housing, Just Services Services Related to housing and another was homelessness is the diagnosis and the other said you can target thing things for people with specific needs. Is there any way to resolve these contradictions and views. I dont think theres contradiction and what we are saying. When people say medicaid should pay for housing, i think what theyre really saying is we need more housing in the federal government isnt investing in housing through the Housing Programs and we need to get it somewhere because you have a health impact. Maybe medicaid should be the thing, but it is prohibited from some things in housing so i have found it to be an unproductive lobbying strategy. Therefore i talk about medicare could at least pay for the things that medicare does pay for which are the Health Services and the homebase support that would allow us to move someone off the street into a home of their own and keep that housing. I dont think those things are at odds at all. I look to my colleagues to see if they heard the same thing. I think the other thing that is important is, in colorado, we have a very dense area but then we have large spots of Oil Communities that also have individuals who experience homelessness. To some make stent the flexibility of letting local partnerships figuring out what resources are available in their community and how to leverage those appropriately is the other piece that doesnt make them in conflict with each other but reflects the diversity of our nation. Im coming from his local perspective where we should really have to pull together, you know public, private faithbased, philanthropic. Everybody had to pull together and this cant go on in our community that we are not providing for the most vulnerable on our streets. I guess that is what we are saying to you is we just hope that we can all pull together. I just think, id be in heaven if i had three had three things, if i had enough Supportive Housing units and if everybody was insured and we had the Supportive Services to surround the person in the housing. Those three things. Thats mind to. If i can, i want to follow up with the question that got raised by the previous question and it involved a former administrator of the Health Care Finance administration and runs medicare and medicaid. Someone had asked him about the reasons we ought or ought not to meld the funding streams between front housing and medicaid more fully. I think the problem with funding housing or seeking to fund it through medicaid is that medicaid is already under all kinds of particle pressure because of expense. You start to say that anything might benefit a medicaid beneficiary if you start to say that anything that might and a fat ought to be covered by medicaid you are really opening up a Bottomless Pit and making the program even more vulnerable to those who want to cut or eliminated. I wonder if i could elicit some responses. Im really confident that he isnt in the room but i couldnt disagree with the short side of that perspective. I think the case studies that are told say that. I think the important thing from our perspective at hud, we have this conversation with other agencies is that medicaid should pay for housing has the whole history of medicaid is doing housing and really institutional horrible, horrible ways. Every time i think theyre doing it better ten years later, its trying to figure out how to downsize and divest itself from what they thought was a really good idea ten or 20 years ago. They do not know how to provide housing. Conveniently, we do. I think its not a question of should medicaid pay for housing, i think think its a question of should the federal government invest in a Housing Program that have enormous human benefit and cost offset on the mandatory side of the budget in order to deal with budget deficit issues globally and deal with the aging americans and americans with disabilities who are living on the street. I dont see see that is a slippery slope and i dont see it as a flat pole. I see that a sound Public Policy to go fix the problems that are costing 328,000 for mr. 280 sorry i got a little attachment there, it it was very on federal of me. I note in one of our handouts there is this chart of state initiatives in this area and the state of new york, in fact, did ask for medicaid money to build housing. And i went and talked to Jason Harbison before he submitted it and i said why are you asking medicaid to do the very thing it cannot do. He submitted it anyway and medicaid said no and what he didnt do is include in that same request, i hope jasons not here, everything that medicaid could have paid for, all of the services and instead they are paying for that on a state general operating fund instead of levering the federal match of medicaid. I dont know why they did that. Sounds like some Technical Assistance is in order here. Yes, youve been very patient. Hello, im from families usa. I appreciate all i appreciate all the focus that you have put on to homeless issues in regard to housing and health but id like to read and that a bit. You mentioned the federal government has the collaboration between key agencies and thats unprecedented right now. I wonder if there are conversations going on where you are discussing improving Housing Conditions rather than just getting people into housings. For example some children who have a chronic condition like asthma often are increasingly going to the emergency room because of the mold in their house. Im wondering if theres any work going on around that. Yes, absolutely. Theres a time hud is doing around the intersection of housing and health and its everything from the environment that we live, to how communities are designed and whats happening in a home. Is there mold, is there lad . And also we need more. When we do more, hopefully we do it well. We have offices that focuses specifically on how to we renovate how do we do home modifications to deal with the causes of asthma, how can we partner with the Healthcare System and the public Health System so we can do that at scale . I think one of the challenges, especially especially with highly mobile families, is there can be a tendency for the Healthcare System to go in and completely overhaul this unit and then you dont live there anymore. I think it will be great as we have one more healthy unit in the world but who pays for it . We would love to pay for it if we had the budget dollars to do that and do it at scale, but i think in the absence of those dollars and we do some funding in this area, but we are really trying to figure out how to do partnerships. I had to think of, for example, partnership we have with Johns Hopkins university and try to do a very targeted strategy in that community. There are some things were doing in california where we are partnering with the city and Health Care System trying to figure out how to do a very concerted effort on that. It wasnt a part of my it wasnt a part of my remarks today but that certainly doesnt mean it is up important part of the work that hud and hhs are doing together. I would just add from a state perspective that that kind of thinking is great thinking and as yet another state agency to the mix in our world. As part of the state of health they have Guiding Principles around those battles that include the kinds of things from a Health Perspective we know we could win. Childhood asthma and other things, it is important reminder to us and again, perhaps we should contemplate adding them to our Interagency Group but it is a piece that is also from it different perspective and in a different place from our State Government structure. The agencies work very closely and it may be a next step for us contemplate. Yes maam. I am a local official and represent hundreds of low income residents who receive medicaid and medicare. There is a push for concentrated poverty where families have many chronic illnesses or health it issues. There is a push to reduce their housing to create mixed communities. Most of my constituents live in fear that within the next few years they will not have housing. That leaves them to become sick, ill, and in some cases they die because they dont know what is going to happen in the future, because a lot of people dont like to see hundreds of low income residents concentrated in certain areas of the city. My question is, how do we secure housing for those that are already housed in low Income Housing, particularly Public Housing using its so we can work on their Health Issues and they dont continue become ill. They are afraid theyre going to lose their connection to their community. That is a terrific question and think you for asking it. We have learned a lot at hud about Community Redevelopment over the course of the last five decades, and i think, when we did it poorly, we kicked everybody out of the building, we tore it down we built mixed income communities and then we didnt know where the people were that had been sent away. I had an opportunity last year to visit that community inkk performing schools in the atlantic area. People of all incomes want to move to this neighborhood so their kids can go to that school. They started as a charter school, k through three, or something and just three, or something and just built a high school thats just opening now. They have a ywca. I have never been in a place where i saw a Young Children of color in the hallways at School Learning with as much pride in a community in atlanta. We can do this. We can do this. The old ways, we didnt do it well. People have a right to be afraid i wish i could take your community down to see this community in atlanta because it is a testament to what it is when we do it right. Thank you very much. In terms of innovation and upandcoming services. Can you introduce yourself . Oh, im darren and we are looking at telehealth for providing health over the internet or tablets or smart phones like keeping people from traveling very far within rule areas or underserved areas. It is sort of a new service to help provide quality care for people. I guess my question is, do you see this playing a role in housing . This could save a lot of money on examples like mr. 280. Telehealth usually prevents people from going to the hospital. 70 of the time they dont need to go to the hospital. Telehealth is absolutely an emerging model that has a lot of promise and is being implemented in a lot of area. We are seeing more opportunities to implement that in rural areas in particular. From a service provider, i think it gives us some opportunities to access a Specialty Care care where it may not be available and often times Public Transportation is not available or feasible. I think this is a really intriguing idea on how we can maybe implement this where we can. I think we might also be overlooking that there are lots of reasons why mr. 280 and a lot of our patients go to the hospital, and its not always strictly out of medical necessity. No doubt, the clients we see are acutely ill, but because there is a lack of stability sometimes the nurses there know these folks by name and its because of a social connection social connection that they are looking for, to be in a care environment where people actually touch you. I think we shouldnt overlook the quality of care that our healthcare institutions provide from a compassionate perspective. I know sr. Adele can speak to the fact that very few of our clients are touched by anyone else except in violence or anger. When when you have had a Healthcare Provider put your their hands on you and a loving caring way for the first time in 25 years, years, that can be lifechanging. I am excited about telehealth but for our clients, being together is really important. All allow all allow sister to add onto that. I agree. I know for rural areas and for people who have no access, when what they really need is a specialist its wonderful. I have that same concern that, you know, just to go back to mr. 280, we had him for three weeks in the rest center and i can tell you he has a traumatic brain injury and poor impulse control. Every time he felt unsafe he would say to us i have to go to the hospital. No, you are fine but he went there really because it was safe, it was clean, it was sheltered and he needed a human a human contact to tell him he was all right. Now can we do that with telehealth . Well i would be careful about implementing it but i think it certainly has its place. Our clients need a group hug, really. The so the compassion you are hearing here is born out of that realization that that is an intense human need for all of us. Okay we have the last question. Thank you i will try to make it a good one. Im janet what the National Housing conference. Im curious to get your thoughts on the panel about Housing Navigation services, internet medicaid doesnt pay for housing and shouldnt pay for housing. Is there there a role for these housing organizations, to even start to think about how to find a home. Whether its permanent Supportive Housing or some other type of unit, what role role do you think that plays in some of these comprehensive Care Services . and sunday evening at seven Susan Southard talks about the city and people of nagasaki japan on the morning it was bombed on august 9 1945 until today. This weekend on American History tv on cspan3 we commemorate the anniversary of the bombings at paris he met and nagasaki japan. The Labor Department is reporting more job gains in july print u. S. Employers added 215,000 jobs will be an i rate held at 5. 3 for second straight month. Job growth has averaged more than 211,000 so far this year. President obama talked about the jobs numbers at the start of a bill signing ceremony for a wilderness site designation in idaho. First of all over the last six years the American People have worked really hard to bounce back from the worst economic crisis since the Great Depression and we have jobs numbers today showing america created another 210,000 new jobs that makes 65 consecutive months of privatesector job growth in this twoyear run of growth that we have seen in the last 15 years and its a testament i think to the incredible ingenuity and resilience and hard work of the American People. Even as we continue to focus on rebuilding our economy providing more Opportunity One of the things we have been talking to folks about us leaving a legacy for the next generation observing the incredible beauty and the godgiven luxuries that we have received those of us who live here in United States of america. I think Everybody Knows one of the prettiest days we have in some of the greatest National Treasures is the great state of idaho. Im very proud to be able to assign this piece of legislation enacted in the house of representatives entitled the National Recreation area and wilderness addition to discuss the designation wilderness designation in the great state of idaho and this is a remarkable area. It is used by fishermen, hunters, rafters people that hike. It is not only beautiful but its also an economic engine for the state attracting tourism and creating jobs and thanks to the work of a broadbased coalition in idaho but spearheaded in congress by congressman mike simpson who was able to receive not a single no vote which does not happen often in the house of representatives. Something that folks have been working on for quite some time. It is going to be a reality so we want to congratulate all of them and we want to urge the American People to visit these incredible wilderness areas and recognized that not only will this give opportunities to people in idaho but it will be there for future generations as well. One last point i want to make we want to be thinking during the course of this summer about the firefighters who are taking on fires all across the midwestern states. As i have noted before we have seen a consistent escalation of the severity and the length of wildfire season and a lot of it is attributable to the fact that Climate Change is raising temperatures and creating less water for vulnerability to a lot of force out there. One of the things we are trying to work on in congress is making sure that we are able to properly fund firefighting efforts but also we are engaged in the kind of conservation planning to ensure that we are preventing fires from happening in the first place. So thats a project that at least the western states can get a lot of bipartisan support for and hope we will be able to get that passed here in washington so again congratulations to all of you. Mike congratulations for the great work you have done. I will now sign the best measure. I have got a lot of practice. There you go. [applause] next a white house news briefing with press secretary josh earnest. Among the items covered white house reaction to the announcement that new york senator Chuck Schumer not support the i ran nuclear agreement. The briefing is about an hour and 25 minutes. We have made considerable progress in our efforts to degrade and ultimately destroy isil. The u. S. Led coalition has now hit isil with more than 6000 airstrikes. The coalition has taken out thousands of fighting positioned tanks vehicles bomb factories and training camps. In iraq isil has lost the freedom to operate in 30 of the territory that they held last summer. Overall isil has lost more than 17,000 square kilometers of territory in northern mark the president certainly stands by the argument he made in the speech at the American University on monday. You cited the two members of congress that have come out in opposition to the deal since the president s speech but there are for now if we do the math here think where up to 12 members of congress that are part of the deal and seven in the house and five in United States senate. So certainly the two members that you mentioned are influential members of congress but they have one vote and since the speech we have gotten substantially more votes in support of the deal and i think thats an indication of how persuasive the president s speech was and how persuasive the cases that is making to members of congress and the American Public. Losing the guy is going to be the number one tie in the senate are they classified as rejectionist further reason the president has questioned . I think what the president took on directly in his speech is that the individuals who are advocating for the defeat of this agreement are the same people who made the same arguments in 2003 in the march to war against iraq. So this includes people like Mitch Mcconnell and john and john mccain and more recent newcomers like tom cotton and donald trump. Thats why on the other side the group of people who are supporting the agreement are those individuals who like the president of the United States opposed the iraq war from the beginning or hit since acknowledged that the congressional vote in support of that march to war was a mistake and i mention some other names already senator gillibrand and senator baldwin are two of the newcomers that there are also people like nancy pelosi and it urban and adam schiff who have strong records on these matters. So anyone and mark you have been in this category anyone covering american politics for the last 12 or 13 years would wreck the nice the fault lines of this political argument. Its not new and this is the difference of opinion that president obama and senator schumer have had aiding all the way back to 2003. That all said, thats why i would describe this as an announcement that was not reticular way surprising to anybody here at the white house. Even if it was disappointing but it doesnt change our competence that we will be able to mobilize substantial majority of democrats in both the house and the senate in support of the deal and if necessary to sustain the president veto. As you mentioned trump [laughter] its cuts force have i said that correctly traveled to question officials on the travel ban. Now that has been confirmed what is the u. S. Reaction to that and both russia and irans on that van. Jeff i have seen those reports but im not able to confirm them however. I think what i would remind you of is we have indicated from the very beginning that our expectation was that this ever to reach an agreement to prevent i ran from obtaining a Nuclear Weapon would not address the longstanding and lengthy list of concerns we have with the iranian behavior. You mentioned mr. Suleimani. He and particular is someone who has been subject to u. S. Sanctions for quite some time because of the effort he has undertaken to support a terrorist organization and again i cant confirm the specific reports but its an indication of our ongoing concerns with i ran and their behavior and the president makes it all that more important that we pursue the best available strategy to prevent i ran from obtaining a Nuclear Weapon and thats exactly what the president will use a diplomatic agreement in. And russia . Again we have found over the course of this diplomatic engagement in the context of the p5 1 negotiations that russia has been an effective partner and International Community and the assistance of russia has benefited from their willingness to cooperate with the broader International Community in reaching an agreement that would prevent i ran from obtaining a Nuclear Weapon. We hope that russia will continue to act cooperatively with the International Community are you not worried . Im not in a position to confirm that individual report rated. Going about back briefly to iran this development which you characterize is not surprising but disappointing disappointing. Is it change the calculations for the Campaign Going forward and does it change your answer to my question yesterday about the president . No i do not anticipate the president will spend a lot of time making calls on vacation. Because possible the president could make some calls but most of the president s timeline will be spent with his family are on the golf course or a little bit of both. Overall do you feel confident about the report that he will come out in favor of it but it still has a ways to go. I think what is clear is there a still a number of people who have not announced a position on this issue and thats why you can expect there will continue, they will be continued discussions between Senior Administration officials and members of Congress Even though the next several weeks that congress is out of town. And we do continue to be confident in our ability to build strong majorities in both the house and the senate among the Democratic Caucus and one of the reasons that is the case is that there continues to be, theres public data to indicate that this is an agreement that democrats across the country support and error ports that indicate there are majorities of American Jewish who support this agreement and that continues to give us confidence that as people consider the terms of this agreement and as they consider the strategy to prevent iran from obtaining a Nuclear Weapon we have a strong case to make in terms of persuading members of congress and the American Public that this is in fact the best approach. One more on senator schumer. A number of former senior demonstrations officials last night tweeted suggesting that between this and what senator schumer said about obamacare in the past that they may not support him as the democratic leader in the senate. Im wondering if senator schumers position on this issue gives any doubts to the white house . Ultimately this is the question for Democratic Senators and this is a vote that they will cast in early 2017. I believe thats the way its reported so this is a line of questioning that came up in this context when senator reid announced his retirement and i said at the time that the white house did not anticipate, this white house at least would not take a position on those future leadership elections and the senate Democratic Caucus. That continues to be true today but i certainly wouldnt be surprised if there were individual members of the senate Democratic Caucus that would consider the voting record of those who say they would like to caucus. [inaudible] the Labor Department said no final decisions have been made. Im wondering if its at a point where its kind of getting through the revelatory language and is there any reason the white house wouldnt support a plan to implement its . Well justin i dont have any comment on your consideration of possible executive actions that the president and the penetration might take to president has certainly made it clear that he believes middleclass families and our broader economy would benefit if more families had access to paid leave but those kinds of policies to help middleclass workers better balancing obligations they have at the office with the obligations that they have at home and when those policies are effectively implemented they have a way of improving productivity and bolstering loyalty to the employer. Thats why we have seen so many private Sector Companies take action on their own to implement these kinds of policies and i know that i believe it was netflix earlier this week got a lot of attention for a paid leave policy that they are and plummeting at that company and they are not doing it out of charity. Im confident they think its good for their business and the president has made no secret of the fact that he believes this would be Good Business for Companies Across the country but i dont have any announcements to make at this point about executive actions and consideration in pursuit of that goal. The president said he saw a glimmer of opportunity for political transition in syria. [inaudible] im wondering what the president has based his assessment on the position of russia and iran on and has the president or Administration Officials had conversations with the iranian government about syria and secondly what is the u. S. Doing to take advantage of this window that you perceive . Are there any other policy changes that you are trying to undertake to take advantage of this moment . Japheth sounds to me like an accurate characterization of what the president said in the interview and the view that he was expressing was based on his own analysis of what is occurring on the ground and i think many analysts with some expertise in this area have concluded that president assads grip on power is not as strong as it once was and i dont have any specific conversation to tell you about but there is reason to believe its not just analysts in the United States that have made this observation, but other registered parties in the region have reached the conclusion as well