Transcripts For CSPAN3 VA Secretary Shulkin Testifies On Veterans Suicide Prevention 20170927

Were live at the Senate Veterans affairs committee, where the success tear will testify about preventing veteran suicides as the committee looks into what congress can do to prevent them. Senator Johnny Isaacson chairs the committee. John tester is the top democrat on the committee. This is live coverage on cspan 3. We call this hearing to order. I thank all of you for coming today, especially our witnesses. We have a number of members on the way, but were in the interest of your time were going to get started. Todays hearing is about the issue of suicide. This month in america is National Suicide e Prevention Month across the kocountry. Suicide is a terrible, terrible, terrible loss of life. John will remember when we came in as a committee our first bill we passed was the Suicide Prevention bill. Passed this committee 990. It will ask to give us a report on the progress on the implementation of the act but its a very important act. And in august of 2014 i held a hearing at Georgia State university as a member of this committee. The reason i did was because in that year the months leading up to august 2014, georgia principal of the va hospital had three suicides, two on campus. A mission handling of available tools Like Pharmaceuticals and things of that nature. Others for a lack of awareness and lack of capacity. That was the real thing that concerned me. We began working in the clairemont hospital innen atlanta to improve vas response to suicide and to Mental Health issues. Suicide is a disease. It is preventable. There are many things we can do to set the example. Our staff director did a great job of seeing to it that every member of the staff has been through the training for Suicide Prevention. Is stands for signs of suicide thinking should be recognized. Ask the most important question of all, are you thinking about committing suicide, which is a tough thing to address, but the key question to ask. Validate the experience and encourage treatment and expedite getting help. I can tell you from what we learned in atlanta and the va timing is everything as it is in health care and most things. The goal we know about in health care, but when someone is contemplating suicide, its not something you put off for an appointment on wednesday or another day. Its something deal with immediately and quickly and expedite the response to it. I want to thank the staff for going through the training. Just like the heimlich maneuver has saved me a life, somebody was choking and somebody else knew how to apply that maneuver and just like cpr has helped people with untimely heart attacks, cpr helped people who might have drown and brought back to life. But being aware of the training thats necessary to save a life is is critically important. Were going to see to it we promote that training throughout the va and throughout the government to see to it we are saving lives and helping people to recover and restore their life. I want to thank bob for his commitment to being on the staff and all the Staff Members for having done it and thank the committee for their effort as well. We have two panels on the issue. The first is john day,en assistant Inspector General for health inspections. And dr. Matthew fits from montana. We appreciate all three of you being here today. Youll be allowed to give up to five minutes of testimony. We dont have a whistle that blows, but after ten youll be in big trouble. With that said, well start with you dr. Day and your testimony and go down the list from there. Welcome. Thank you, chairman isaacson, Ranking Member, members of the committee, its an horror to testify before you today on the subject of Suicide Prevention. This topic issen important to all of the staff at the oig. We work to receive veterans receive the highest quality Mental Health care. We have reviewed facts surrounding the death of veterans that took their own lives. We find they suffered the effects of chronic Mental Illness and Substance Abuse disorder. In the aftermath of these deaths, we hear from members of the veterans family, c significant friends that they would have acted sooner or differently only if they had known. After the Virginia Tech incident shootings, a serious review of the privacy laws that impacted disclosure of medical information was undertaken. My staff met with and talked with a number of the individuals who were involved in this review to determine if there were Lessons Learned that could be applied to va. Changes to law seemed too difficult to design, however, changes in practice that utilize advanced directives or similar devices may offer a way to improve communication at the criticalen point when a patient needs help the most. I think there is a chance to improve communication by expanding the situations underwhich these and similar devices are used. Va is thoughtfully derived to predict who may suicide. The question is when would a veteran take action to harm themselves or harm others . When would intervention be most effective . Research using social media and other more timely data has shown promise and understanding the human emotional state and therefore, may assist in identifying when intervention for these atrisk individuals would be most successful. I think pilot studies and this has great potential. The testimony of others at this table point out that veterans do not obtain their care primarily from the va hospital system. So an effort to. Reach those veteran who is are at risk is most appropriate and essential to make a significant improvement in veteran suicide data. This concludes my oral testimony. I would be pleased to answer your questions. Mr. Chairman, mr. Ranking member and members of the committee, i appreciate the opportunity to appear here today to discuss recent advances in veteran Suicide Prevention. I want to read my written testimony in full, but will highlight a number of key points. The response to rising suicide rates the va has implemented numerous measures to prevent suicide among veterans. These efforts have led to improved access to care and serves as how they can prevent suicide. Several new studies reporting related outcomes among military personnel have been published in the past two years. While most of these studies their findings are applicable to the veteran community as a whole. As summarized in the attachment to my testimony, all the interventions reduce suicide. But only two are associated with significant reductions in suicidal behavior. Brief behavioral therapy are found to reduce behavior by 60 to 76 . Its those who served in the military. These treatments now serve as a foundation for several studies currently underway in the va and the dod. These latest findings not only confirm that behavior can be prevented among military personnel and veterans and shows how to do it. If these studies telt us anything, its that some strategies work better than others and simple things save lives. Tragically few veterans are likely to receive these treatments for a number of reasons. Today ill focus on one particular barrier. Inadequate training in Mental Health professions. In these studies researchers found that a key Suicide Prevention strategy used was not associated with subsequent reductions as was expected. The lack of effectiveness was attributed to poor quality implementation. Of note, the personnel did not implement the liability or specifici specificity. Researchers from both studies concluded that the results pointed to insufficient training and additional training could change this course. The problem of training is not confined to the va, though. Tragically deficient training is indem ic across the mental healh system. A recent report from the American Association of suicide highlights this issue. The Main Findings of that report are smarz ed in the attachment o my testimony. As you can see a shockingly low number of Training Programs provide any education or training about suicide to its students. Further more, state licensing boards, the very bodies charged with protecting the Publics Health and safety from unqual y unqualified professionals do not require any exams or demonstration of competency in risk assessment. The complications are disturbing. The vast majority of our nations Mental Health professionals are unprepared to effectively intervene with suicidal veterans. This has critical implications for all veterans, both within and outside the va. We have long talked about the many barriers that stand in the way of a veteran receiving Mental Health treatment and invested heavily in removing those barriers. What unsettles me the most is knowing that when a fellow veteran overcomes these barriers, he or she is unlikely to receive the treatments that are most likely to save their lives. A sobering and uncomfortable truth is we have made it easier for veterans to obtain treatment that doesnt work, especially those who receive services from nonva providers in their communities. If we want veterans to benefit from the most recent advances in Suicide Prevention research, well need to ensure implementation is accompanied by a robust training program. Luckily the past few years have led to considerable advances in our understanding of the most effective ways of teaching these methods to others. In order to reverse the trend, we must be willing to disrupt the status quo. We need to adopt the newest strategies that have garnered the most support, even though they may depart from existing procedures. We need to invest in training to use these procedures and create new initiatives to incentivize and support their implementation and clinical settings. These changes should not just target the va and dod but all settings. As well as our universities and Training Programs that are responsible for the readiness and preparedness of the Mental Health professionals. In conclusion, we are at a critical turning point for Suicide Prevention. Answers are now clear and effective strategies have been identified. We must now take the steps needed to ensure the treatments and interventions are easily available to all veterans both within the va and our communities. Thank you very much. Chairman, Ranking Member and distinguished members of the committee, on behalf of montana i would like to extend our gratitude to share our views and recommendations. We applaud the dedication in addressing the Critical Issues surrounding veteran suicide as someone who has lost a Family Member that was a veteran and just want to appreciate my sincere thanks. Montana has the highest suicide rate in the country. This is significantly higher than the National Veterans suicide rate and the western region. We think its important you have a framework to understand that the suicide, the model that we use is the stress model in which a combination of biological susceptibility that lead to malfunctioning neuron communications, which. Develop into behavior. The therapy and the support of family. Youll note that i will not be coming restriction because i believe its incredibly hard to legislate that, but it is an important factor. This creates unique challenges for our Health Care Providers and we are deeply in need of more Mental Health providers. Ill move on to our recommendations. Our first offer of intervention is proven to reduce suicide during critical points of military and veteran experience. It was influential in bringing the youth aware Mental Health program to the United States and we would like to offer it as a template of something thats proven to work in another population and would be perfect to bring over to this one. Second recommendation, establish a clear policy goal to improve the diagnostic treatment system. The target that we recommend to the committee is a task to work with the department of defense, the National Institute of Mental Health and the private partner to prepare two additional brain diagnostic measurements for clinical work in the va by the fall of 2020. Our next recommendation is to develop a plan for treatment resistant Mental Health conditions. Rough ly a third of mental healh conditions do not respond to traditional treatments. And this is a big issue and its an issue thats not addressed in montana. The va has nothing in our state to address treatment resistant depression. This is very personal to me because i lost a dear friend and it was a veteran in september of 2015 to treatment resis tapt depression and to watch his options slowly slip away was one of the hardest things i have ever seen. Montana blue cross and blue shield supports tms treatment for depression. I do not know why the va does not. Expand access to psychiatry and make online behavioral therapy available to all veterans. We also believe the va should expand availability of automated suicide risk assessments, develop a prize to create and validate a medical screening to determine which patients are at risk of developing side effects, develop a public facing Online Research directory for nonva resources. Create a relationship between the va and community Mental Health centers. There are over 1300 Community Health Centers Across the country and we should be working with those to care for our veterans. Increase the vas collaboration with outside researchers and finally establish a continuity of pipeline for veterans directly from the department of defense to va and Community Providers. Thank you again for the opportunity to testify in front of this committee. Your attention to this issue means a lot to me, our entire organization and their families. Thank you, we appreciate you being here today. What im going to do is reserve my time. We have different meet thags are going to take place. Im going to go to members and their questions and ill ask mine later when senator test returns. Hes doing another presentation. Let me start off with john. Thank you very much, mr. Chairman. Thank you for holding such an important hearing and also to senator tester. I cant think anything thats more important to discuss. Certainly we all agree this is a crisis. In arkansas i think were number ten in suicide rate overall. Of that group, veterans represent about 8 of the population but represent 20 of the suicides. So we are a state that is like so much of the rest of the country. In fact, the rest of the country period is experiencing significant problems. Dr. Brian, you mentioned that recent reports have highlighted the inadequate sis of the Mental Health professional. And in fact i was looking at the chart 25 of social workers, 2 to 6 of marriage counsellors. Those have received what we call even the Old Fashioned training perhaps. Not to mention the work that you and others are doing in such a good way. Those are are pretty staggering. Unless we have a metric out there, how do we go about solving that problem . I will admit also as youre thinking about that, and the rest of you can jump in too. Once we have the new research, once we perhaps get a metric, how do we get that not talked about but instituted in a timely manner . Both very good questions. The first it would probably require a concerted effort in it redesigning and reengineering our education and Training System and professional practice of Mental Health. We would need to find ways to incentivize graduate Training Programs to sure that not only is that training scientifically supported. This can be established in a a number of ways looking at grants and other federal incentives and initiatives to encourage certain types of curriculum and training opportunities. To look at how do we determine whether or not an educational system is meeting minimum standards for the practice of Mental Health across these disciplines. If we work with those organizations, i think we will be able to see some very dramatic shifts in curriculum. For your second question regarding dissemination and implementation. I think one of the challenges that many of us have as scientists is a scientist not to be very good at communicating their ideas to nonscientists. And so many of us in the dissemination field have talked about how do we find opportunities to have researchers and scientists work with Communications Experts on how to convey this information not only to the general public but also to other professionals. Those who we want to target to be using these strategies, but we also need to target the consumer. So the consumer is educated and understands which treatments work best. So when they go to a health care provider, they can ask the right questions to determine if this is an individual thats likely to be able to help me. One of the things we found to be important is getting the research to the states. Creating a pipeline to have those conversations. We had to start up our Research Center in montana to make that happen. And because of the way the structure is centralized Research Well probably never have va research doing much in montana. If that pipeline is adjusted, that gets those conversations started. It gets people trained. The other thing that i would recommend is for the va to make its treatment for veterans more widely available. I think that the transition with the medical records is going to make that more possible. But get those treatment algorithms out to the field so the facilities can use them. Is overmedication a problem . The response is broad. What we would see a student of mine just finished their dissertation and about ready to publish the results a larger than expected proportion of veterans who receive benzos, that are not indicated and can interfere with effective treatment for ptsd. Often times physicians and providers lie on these because they have not worked. So they are hoping to provide some kind of symptom relief. The unfortunate aspect of this is what we have found is in those cases, those veterans with ptsd, but almost three times more likely to die by suicide. So theres another risk associated with contra indicated medications where i dont know if they are overprescribed, but im not necessarily certain that in all cases veterans and prescribe rers aware of all of the risks and are able to weigh them with the benefits of those medications. Thank you. Senator blumenthal. Thank you, thank you mr. Chairman and thanks for your leadership on this important issue. I was the lead democratic cosponsor on the bill along with senator john mccain on the republican side. Believe it was a start but only a first staff in this effort. Obviously there are steps that have been taken by the va and furthering this effort and well hear later, but the more i learn about this problem, the more complex and challenge iing i th it is. One of the very important statistics in your testimony is that the suicide rate among veteran who is do not use va services increase by 39 from 2011 and 2014. Where the suicide rate among va users increased by only 9 . Put aside the exact numbers, what i am hearing again and again and again is is that the suicide rates are increasing among veterans who lack access either because of geographic or other difficulties in reaching these services. Or because they have receive d less than Honorable Discharge. This has become a passion for me because there is a whole group of veterans who suffered from pts often undiagnosed or separated less than honorably and have been cast out and barred from using those services and often feel stigmatized and dise disengaged from society in general. I have met with many of them and i have worked with the department of defense on the review process, which has been changed as a result of leadership within the department of defense commendably, but many of those veterans who were discharged less than honorably dont know about it. Dont know about the changes in policy. Dont know about the possibility of access to these services. So it is a vicious cycle a lethal cycle chrks can lead to suicide. So i guess my question to all of you not only about less than honorably discharged, but Women Veterans who also perhaps do not readily access these services and their suicide rates are increasing. Those segments of the veteran community whose suicide the rates are increasing need to be reached and my question to each of you is you see that phenol nonas real. Do you recognize it . Can you elaborate on it . What are your recommendations for addressing it . Sir, i agree with you. I think the adequate treatment of Substance Abuse disorder and access to therapy and the adequate treatment of depression to include farm logic treatment or other treatments that are available is critical. So if you cant get people to a provider, its a different problem. So i agree with your statement. I have two thoughts in response. The first of which is i think the successes highlight is that the rates are going up. Even among va users, but its a a much slower rate. So the va is doing something good that is not happening for those who do not receive the services. I think we need to ask why are there not other adequate Services Available to veterans and their communities. And i think this really came to ahead for me several years ago. I dont know if you read the article about the marine who had a high suicide rate and a lot of them did not have access to the v skparks a lot of discussion about that. The ill pli indication of this is that some veterans have access to nothing. Or they have access to Community Providers who have little to no service. They have never seen traumatic brain injury before. The statistics have no experience with suicide risk. And so i think part of the solution how do we get more veterans into the va because as the b rand report recently released the quality of care from the va exceeds that in the private sector. Sol veterans choose not to. We need to make sure Quality Services are available to them. Our center is on the University Campus across the street from the va. What we say is were not a competitor to the va. Were the augment. And so the va sometimes sends their patients to us for treatment and theres some veterans in the community who cannot do it at the va or unskplg they come to us and we can sometimes connect them with the va for other services and benefits that maybe theynt department know. So i think we need to look at models like that on how Different Community agencies in the va can further strengthen working together to better meet the needs of all veterans. Senator blumenthal, thank you for bringing up the less than honorable issue. That was something that came up in our family. One of the ways that it was solved was by adding a vet center to our community. At the time the va had fought it because they said that you already have a hospital. Everybody that will go there that would go to the vet center is already going to the hospital and that turned out not to be true. Part of it is when youre depressed or have ptsd the first thing you cant stomach is bureaucracy. And you just quit. And the vet centers have less bureaucracy. I think that thats part of whats not really shown in those statistics. The folks that give up because they look at the bureaucratic red tape and say i cant mentally take it. I just want to thank all of you for your testimony today. Obviously, we just scratched the surface of this topic. I hope that we can get the latest numbers on that suicide rate. I sponsored legislation with senator blunt to call the veteran peer act. In patient align care teams within Va Medical Centers to do this kind of outreach. The peer to peer relationship. But the va has been doing better and i commend the team and as i mentioned will be hearing from him but on all counts the nation needs to be led. For the benefit of the the members were going to take questions. The next three will be senator mansion. Thank you for this hearing. I want to thank our witnesses for being here today. I want to thank senator tester, because i know this is an issue thats important to him. An issue thats important to montana. And it is unfortunate that montana leads us in this statistic but the issue is nevada is right behind them. The question that i continue to ask myself is what makes montana and nevada unique. Why we see the stress in the areas of montana and nevada, maybe a little more unique than the rest of the country. It will probably be making more money. We do have higher access to lethal means in our state for the most part. When youre suicidal, the closer you are to committing suicide, i mean, is very real. We also have a lot of veterans per capita in our communities. And i think that thats important. One of the things thats a little bit different about our suicide trends, and i dont know if its the same for nevada, is we have more older veterans that are killing themselves and i think that theres National Trends saying that its younger, but if you look at montana, that age 30 to 65, white males is when were losing them. We have no psychiatric residents in the program in our state. I know that a lot of nevada communities struggle too. I think its a number of different factors. We have to tackle them one at a time. E he expressed his efforts and trying to tackle this particular problem we have hospitals north and south end of the state. We have a a number of clinics that have been opened recently and the work of the secretary. They have a program in israel that maybe we already discussed this. They try to get this ob the front end instead of the back end. Where they actually train soldiers both male and female of trying to avoid some of the stressful situations they may find themselves in and train them for them. Are we doing the same thing in our country . I would say in general, yes. If you look at military training in general, a lot of it is designed to foster resiliency. How to endure difficult situations to perform under pressure, manage stress, et cetera. Where we have not had had much success over the past decade is when we try to. Develop new programs that take more of a classroom format. E we bring in outside expert who is teach or train sometimes trainers b within the units or resiliency expert who is are supposed to go and teach these concepts and skills to others within the unit. There have been a number of barriers to that, but some of the research thats been done on some of the larger resiliency programs are just soldier fit and yielded no benefit. We have seen some promise, however, in other resiliency methods. One that has garnered the greatest promise so far is a program developed by the army called battle mind that was shown to prevent or reduce ptsd symptoms. It was a small and noticeable degree amongst those who had the greatest and most intense levels of combat exposure while depl deployed. We have evidence suggesting that certain approaches might help to prevent at least reduce the severity of ptsd. However, we have not been able to implement and further study those different strategies. Is there any family training so that they can identify some of these issues prior and prepared to help that veteran. There are a number of programs that have been created. Theres none that rises above the top. Where a lot of the family Training Programs and this actually is common. The peer issue a will the of the programs takes a bunch of signs of symptoms of this Health Condition and now refer someone to a Mental Health professional. What we lack is what do the Family Members do. So if a veteran is struggling and does not want to go to treatment or theres a twoweek wait, what are you supposed to do in the meantime. We dont have any programs training that. Newer research, the Crisis Response appointment i mentioned before, this is something we have been teaching the Family Members. We have been teaching the peer specialists. We have been teaching the nonHealth Care Providers in the community who are closest to the veteran in need. Didnt really neck news when they need help but what to do about it. And doing things that have been shown to prevent suicidal behavior and reduce ptsd. I want to thank our panelists. Thank you. I want to thank the secretary who is in the audience for his commitment and coming out to the state of nevada and expressing his concerns on these issues because it does make a difference. We need to figure this out and we appreciate it. Senator mansion . My first question as you mention in your testimony a critical part of providing rural areas in your state and many state. In West Virginia, Community Health centers treat patients. Thats 25 of our population. And we have 166,000 veterans in our state. Im sure many of them got treatments. So they lived out in rural areas of West Virginia. I just like to hear you speaking on the importance of the Community Health centers as member tall Health Providers in your research. Are they capable of the personnel and expertise tooed that. Im trying to get to treatment as quickly as possible without trying to build another infrastructure to do it. If this vehicle is available for us. Thank you for your question. Its an amazing point. I tell you that we have our licensing board in the state of mthd. And we have that worked and have lcsws that work at the va. Psychologists here, this is the same level of staff. The training may be a little different, but the rural Health Centers are adding Mental Health professionals all the time. The quality of care for veterans can be as adequate there as they will at the va centers. Yes, sir. The only thing they are not that good at is longterm care. So i think that that shortterm turn around coverage maybe six sessions of counselling until they are transferred to the va. If youre in a time crunch, that is exactly a place where i send people. If youre struggling to get into the va. In your testimony you high lited ab inaud adequate training. Among the professionals, not just va providers, but nationwide. We know veterans are using nonva care, as we just talked about. So my question would be if the Committee Moves forward ob efforts to be working on nonva care, how can we incentivize training. How do we get more people with Suicide Prevention . I think it will require multipronged approach. I think the easiest or sort of most straight forward approach is to invest in training workshops, however, i will say that will likely have limited impact. If theres one thing i have learned over the past decade going to two days of workshop and continuing education and power point slides. To use the therapy and an effective way. One of the things we have learned from a will the of the vas efforts in educating is you have to provide ongoing support and train people and supervise them and meet with them on a regular basis. You help them and teach them how to overcome common barriers. As we look at training, we have to look at this as a longterm support. The second aspect is we have to look at our educational system. Another lesson i have learned over the decade of doing this training professionals at all levels is that if you teach a student how to do good medicine they spend the next 30 to 40 years of your life. Scientifically based interventions. It becomes difficult to change back. So when i really think of the question not only trading the Current Labor Force but how do we change how we train and teach the future of labor force. The requirements for share treatment information to coordinate and prove mental help between the provider. As it stands more than half a million va patients are abusing opiates. Its more than doubled the national average. Its a horrible problem in my state of West Virginia as most states are dealing with this. While the va has made significant improvements i still believe the areas that are critical must work on. I introduced ab act in 2017 to streamline the Health Records sharing between Community Health providers since were beginning more services and outside the va. The bill requires the Veterans Health administration to comply with hiipa but ensure it is can based on the wholistic medical history. So can you please elaborate on your findings as to why its so important for the providers to have access to this behavioral Health Treatment information for the patients and how the current role is undermining the care and hurting veterans. What do we need to do to change . I dont know if i can answer all of that. I think in the personal relationship between the team at the va who is providing care to a veteran, they often know who the significant individuals are in that providers life. Not necessarily related members. So i think that coming up with mechanisms and va does currently use advancedive directives and consider how they could be used so when people get in crisis, va providers can reach out and talk to significant individuals to try to bring that person back in. To the second point of sharing medical records across, i think that the data exchanges have to work in order for the va medical record to communicate with all those other medical record systems. So if there is among the viable points Going Forward. Thats ab extremely viable point. Im not ed a advocating that the some change to the privacy roles. Im advocating that we be more creative in getting permission so that at the time a person is in a Larger Community can be brought into the discussion. Were going to need your help on that. We have had trouble getting past that. We have a bill called jesses law. She overdosed and died in a hospital. She died because when she went into the hospital, she explained she was a recovering addict and she had asked to notify my records and make sure they are identified that they know that im a recovering addict. The records are burr rid. It wasnt like it was allergic to cortisone or the other types of things that really stand to mark the dispensing doctor didnt see it and gave it and they gave her 30 oxycontin. She was dead by 1 00 in the morning. Were having a problem getting through the hipaa because of patient privacy. Common sense has to prevail. Within the professional ranks that you can better serve them, you need to speak out on that one. Thank you. Thank you, senator manchin. Senator montana is back. Were going to let you do your Opening Statement and questions at the same time. Well, first i want to thank senator tester because weve worked together the past year or two getting the with department. We had a good meeting with dr. Shulkin in our office. I appreciate your continued very valuable contribution to us keeping track of the transformation efforts within the va. Im sorry as i was not here earlier to hear the testimony. Well start back on the medical record. Back in knock knock, i stat on the Electronic Health record board when we were trying to integrate Health Records among medical providers within the state. And since im here and im on the Senate Armed Services committee, we were successful with getting a provision in the nda that makes absolutely certain and i believe that the department is glad that we did, the va, makes absolutely certain that we dont miss a step as we integrate the two platforms. Theres still a lot more work to do. With over 120 different instances of medical records in the va, weve got to make sure theres a good flow from d. O. D. To the va and then weve got to make sure we get that right. Then we go to the next step, which is all the providers that could be providing a veteran care. There are ways to do it. We need to push the envelope. We want to make absolutely certain that the comprehensive view of the veteran in terms of their Health History is known to anybody who may provide them care at any level. Im kind of curious about the work that we need ive got the state the heartbreaking statistics for the state of North Carolina. Frankly, theyre in some cases better than the national average. Which led me to wonder to what extent do we see a correlation between the incidences of suicides and other states and the lack of va Resources Available to them or other resources. In a state like North Carolina where we have such a large military footprint you have a Natural Group of people that have a therapeutic value just by being around other veterans. And then we have brick and mortar facilities. Have we looked at that to see if theres any correlation between footprint and outcomes, to your knowledge . No, sir. The gentleman who compiles the data may have an answer to that question. I think its important because as we go through and take a look every one of our states are very different naps why some of the performance of the va differs. Its based on support networks, bsos, a variety of other factors. I dont know. I saw senator blumenthal i think he was probably heading out of the hearing as i was moving in, but i was curious if he brought up the issue that he had a concern with. It has to do with possibly bad paper and not tracking what more should we do to go back and take a look at discharges other than honorable, that if we had had a better understanding of what may have occurred during their service, that could put them at a higher risk and actually could have resulted in paper that they shouldnt have been discharged with. Yes. He did raise that issue. This is i think an important issue not only for suicide but also for a host of other social issues that are of high relevance. Weve seen high rates of homelessness, high rates of criminal activity in that subgroup as well, other social problems. If we address it here with Suicide Prevention, we actually probably would have a much larger social impact in other areas as well. While we deal with the policy issues of how do we go back there are two pieces to this. Going forward, how do we make sure that at the point in time where were making a discharge decision that were taking in factors, particularly the invisible wounds of war that could have affected that persons behavior and resulted in the other than honorable. And the statistics here show that a lot of the suicides that were seeing arent in the current wars were fighting, but theyre vietnam and prior to that. Has there been much work done or any bright spots that you see going back and going in that veterans population and try to help them, trying to get the care they need and avoid the possible suicide . Senator, probably the best one that ive seen is the vet centers. Because if youve been in combat, they dont care what your paperwork looks like. So there is a place where people can go. And the other policy statement is these Mental Health conditions lead to conduct that eventually can get you discharged. And if youve been to combat, why is there a less than honorable . I dont know if we can scientifically say this didnt cause your behavior or didnt have some kind of effect. My perspective, the tie goes to the runner. Yeah. Ill take that at face value. It may be something that we should talk about. Id chair the personnel subcommittee and Senate Armed Services. Even in the u. S. Military, there are people who do things that i think are appropriate for disHonorable Discharge. Its a matter of how you get that right and how you do based on the circumstances that a soldier was exposed to where maybe the tie brabreaker is th one other point ill add to that is if you look at some of these decisions, there are two separate processes by which a Service Member is separated from military service. Theres the medical service and the administrative process. They do not parallel each other. They dont necessarily interface with each other. Sometimes there is confusion about who has precedent because both issues are going on, which one goes first, which one goes second. And so it can create a lot of confusion and a lot of frustration for everyone involved, the commanders, the Health Care Providers and the Service Member and the veteran. So perhaps something Going Forward is how do we create a process where in these two separate parallel tracks, maybe Work Together a little bit more explicitly. Theres now policies in place wherein theres cross talk amongst these two stove pipes right now that isnt happening. Its a little easier to make these types of decisions which i think would help to reduce a lot of these conflicts. Thank you. Senator tester. Thank you, mr. Chairman. I wasnt even going to talk about this but i would just tell you that the easy thing for the military to do is pitch somebody out if theyve got behavior problems. The more difficult thing to do is talk to people, make an analysis whether combat changed them. Its incumbent upon people to do that. This is for either dr. Brown or dr. Day. Could you give me an idea on what percentage of veterans who have attempted suicide for previously diagnosed with Mental Health issues . When you say attempted suicide, they died by suicide or made a nonfatal attempt . Attempt. I want to say the va report says somewhere around 70 give or take. Have already been diagnosed with a Mental Illness . Right, yes. Have we seen a correlation between combat exposure and suicides . We actually publish add paper on this a couple of years ago. The answer is a little more complex to answer. Is the relationship between deployment in general and suicide . No. Thats fine. Is there a correlation between exposure to certain types of combat related traumas . Yes. Its killing and exposure to death. There was a small correlation. There has been some research that indicates that living at higher altitudes could impact suicide and depression. Are you familiar with those studies and are they real . Yes. Actually its a colleague of mine at the university of utah Perry Renshaw is the leading scientist in that area. And theyre reel . Absolutel real . At higher levels we ha interesting. Yeah. This is i think more for you, matt. Veterans have been concerned about, you seek Mental Health care, theres a stigma attached, it could have effects on their career, perception by family, friends, right down the line. Do you think were making the appropriate steps to take care of the stigma thats associated with Mental Health issues . Have we made any progress in the area of destigmatizing Mental Illness . Senator tester, i think weve made some progress as a society. The one thing i guess i just dont understand why we dont do enough of is really brag about how some of our best americans had Mental Health conditions, had post Traumatic Stress disorder. When youre talking about abraham lincoln, why arent we saying, bless us that that guy had bipolar disorder or depression. I mean, i think that some of our greatest leaders like were bringing a Sergeant Major from delta force to congress in november. I mean, people like that need to stand up and say, in some ways my condition helped me. But on those days where i struggle, you better be there to help me too. Right on. You talked about older veteran suicide. And this kind of goes back to the question i just asked. Can you give me an idea whether the newer generation of veterans are seeking Mental Health care more readily than the older generation, or is there no difference . I dont have the data on that. Yeah. I dont know the data offhand. My sense is that there is a decreased likelihood of younger generations of veterans to Access Services at the va. Really . Its actually gotten worse . Thats what i understand. I could be wrong but that was my understanding from some of my va colleagues. One of the things that i think is interesting, we were contacted by a veteran from montana in the far eastern part of montana, very rural, who noted that the va is unable or unwilling to include Family Members in the intervention process if a veterans in crisis. I dont know if this is true or not, but if it is true, i think were making a big mistake. I would love to hear all of your opinions very briefly because youve only got about a minute left, 30 seconds, on what the va can do better to engage families. Dr. Day . I think that use of advanced directives or some other mechanism that allows providers to talk about otherwise prohibited information to families widely when theres a crisis would help that intervention process. I think there are two key strategies that we could work on with Family Members about. The first is basic crisisme management. How to talk to someone in crisis and how to help them. Working with the families to train them so they could recognize correct. This is something weve been doing in salt lake city, training Family Members on what to do. The second related piece of that teaching Family Members and bringing them involved in the firearms safety aspect. How do we work with families to inkr increase safety within the household even during times of not crisis, because if we have a safer household to begin with during a time of crisis, everyone in the house will be safer overall. Do you have any statistics of how many suicides by veterans are committed by guns . The vast majority, close to 7075 are through firearms. Okay. Senator tester, i think telling the families how to communicate with the va, because you can get around hipaa. You need to send us a let person you need to send it to this portal. You can call us. We may not be able to tell you about the veteran. But if your veterans in trouble, this is how you communicate to us and this is the way you do it in a way that well respond. We tell our families you do written letters to professionals. They start thinking about malpractice and pretty quick theyll get moving. But you have to train those families. We have a family to family course which helps train them in how to interact with the treatment system. Well, thank you all for your testimony. I mean, we could spend all day long on this issue, truthfully. And we could spend all week and maybe the next month. But i want to thank you for what you guys are doing. Each one of you in your own right are doing some really good work. I think the key is to partners with you to really move this issue where we have better out reach, education and results. Thank you. I have a couple of quick questions. And well go to senator cassidy if he has a question. Then well go to the second panel. Real quickly to this panel, mis there a biological susceptibility test that you can give one to find markers or indicators of suicide . I wish there were. There is not a test now. Biological susceptibility, its something thats also dependent on other it can factor into every other health care condition. Theres not a buy roj cal s biological test for skin cancer either. We have asked the committee for more biological indicators by the fall of 2020. Even if its not a specific this test for that, there are things like computerized executive functioning where we know if that executive functioning is getting worse. Theres something going on in that brain. Its not necessarily ptsd or depression, but there are tests that need to be brought forward. Im hoping they can be rolled in by the fall of 2020. When you listen to the testimony of all of you, there are two things that pop out. One is we havent had enough good training in the va for dealing with suicide and we need to work on that. The other thing is that people dont ask the right questions. Our timing is never very good. Response timing on Suicide Prevention ought to be immediate and not an appointment two weeks later down the road. Thats why im so proud of all of our staff have taken the save tech course and now understand how important it is to look for the signs of suicide, to ask the question are you considering suicide, not beat around the bush about it, to validate the experience and encourage treatment to expedite knowing what to do is 90 of solving a problem. 100 of solving a problem is identifying it. Everybody wishes there was a biological test. But youre right, there are indicators. I apologize, gentlemen, if these questions have already been asked. You mentioned that in your studies that its unclear how do you establish intent. Let me ask. If somebody dies from a Drug Overdose, say john belushi, is that considered a suicide or is that considered a Drug Overdose . So in the course of our work, sir, we would rely on what the medical examiner said and their determination of all the relevant facts at the time the death occurred to state whether they thought it was an accidental death or intentional death. So accidental in the sense that they are addicted to drugs, they took too much, they stopped breathing. That would not necessarily be a suicide. That might indeed be considered accidental overdose. Yes, sir, we would have that interpretation. Wed always wonder if we were right. Got that. And mr. Bryant, you mentioned that. But any of you all can answer this. Clearly you cite the statistic that 30 increased rate of suicide among veterans. I think thats compared to the general population not to an age gender based doucohort. Intuitively people with greater Disease Burden are more likely to commit suicide. As we understand these statistics, are they matched against a match cohort or is it against the general population . And if they are not matched against a match cohort what are these excess rates relative to win which is matched . So the statistics i cited was from the vas report from last year. Those are age and gender adjusted for the reasons that you note. What about sec . I dont know what other variables they may have adjusted for. But age and gender age and gender are the most common adjustments that we make when looking at veteran and military suicides and comparing it to the u. S. Population. From a general knowledge, i dont know. Is suicide more common among clearly suicide would be more common among people who have addictions. Thats intuitive. Right, yes. So if we look for instance like in the va report, they broke things down into different age groups, they looked at different diagnostic characteristics, what type of Mental Illness does a person have. Men versus women. What we tend to see is on a whole veterans have a higher rate of suicide regardless of the categories. But im asking the general population. Senator cassidy, it can really speak well to montana. But i think since were the highest suicide rate in the country, there may be something to learn there. We created a Montana Suicide Review Team that went through all the death certificates in the state for exactly the reasons youre talking about. We cant solve it unless we know it. Interestingly enough, the one demographic that really jumped out was white males between 30 and 60. Let me stop you. Theres a research out of princeton which says in the general population white males, to a lesser extent white females in that demographic are dying. But it does relate to lower socioeconomic class. Your state has a higher rate of poverty than, say, new jersey. Yes, sir. Have you corrected that for kind of economic status or not . Sir, from looking at the economic status, it will also say that most of our suicides are from people who are economically struggling, in particular people who have not a lot of education. The higher you go up the education totem pole, the less likely you are to commit suicide in our states. There are some other factors that weave into this. If you have depression, anxie anxiety are these veterans a typically lower socioeconomic class et cetera . How closely do they match this princeton data . I yield back. I just i think that mr. Chairman im done with this panel. While theyre setting up for the next panel, id like to make a quick statement if i could. Well do that. I want to thank the panelists here today. Your testimony has been eye opening and helpful. We thank you for your attendance today. Well now switch the table around for our next panel. While theyre doing that id like to give a quick statement. The Ranking Member is recognized. This discussion is very, very important today. It continues to be unacceptable. We have the number of suicides in our veteran population that we have. Make no mistake about it, its also a national epidemic. Not specific to veterans, but were here to talk about veterans. In fact, it is the 10th leading cause of death in the United States. Va data suggests that approximately 20 veterans commit suicide every day. On average and this is an important statistic only six were enrolled in va health care. What does that mean . Weve got to do a better job of out reach. Weve got to make sure those folks have the Health Care Professionals on the ground within the va to get the help that they need. Why is that important for this committee . If were going to get Health Care Professionals on the ground in urban and rural areas and i think theyre needed in both its going to cost some money. Weve got to be more depress ag on this. We need to fill those vacancies within the va. We need to fully leverage the assets like our va centers. We can talk about this. I think its important to talk about it and gets facts. As matt kuntz says he not only talks the talk, but walks the walk. We need to make sure we follow up this Committee Hearing with action that actually does right by our veterans and this country. If we do that, i think it helps the civilian population too. It was an excellent panel and i appreciate your leadership on this entire issue about suicide. We want to do everything we can to make sure were addressing it within the Veterans Administration. We worked very hard in the first nine months of this year, the Ranking Member and i, to bring legislation to the floor to improve the va. Weve changed the paradigm in the va. Weve changed headlines at the va. Were very proud of that. One of the reasons weve done it is weve been united. Also the va is seizing the advantage weve given. I just want to acknowledge that this week or last week was the first use of the accountability legislation in the termination of a Senior Member of the staff of the Veterans Administration for a lack of performance, incompetency. That would not have been fobl that legislation had not passed. I want to thank you for taking advantage of the tools you have asked for and weve given you. There are a lot more tools in the bag that you need to use and were going to be there to support you. I want to acknowledge publicly and thank you for you without further adieu dr. David shulkin and dr. Carol to assist him if necessary. Great. Thank you mr. Chairman. And good morning senator cassidy, senator murray, senator manchin. The best attendance award. Thank you for staying for the whole thing. And i want to thank you, mr. Chairman, for several things. First of all, i couldnt agree more with your comments. Im very proud of this committee. I think its the best committee in the senate. It works together in a bipartisan way and working to really get things done. Im proud to be worki ining witu all on that. And also thank you for having the first panel first. They got all the hard questions and i got to hear all the answers and that was terrific. Were here today and this is an important hearing. Our goal is to eliminate suicide. We want to do that through risk identification. We want to do it through effective treatments, education, out reach, research and strategic partnerships. Senator tester mentioned right before he left that our Research Shows that 20 veterans a day are dying through suicide and he did something by saying there were six americans who died during the course of our hearing. I think about that every day, how many veterans are dying for us not being more effective at the way were addressing this problem. We know veterans are greater risk for suicide than americans. This is an American Public Health Crisis but for the veteran population even more so. We do know that 14 of those 20 arent receiving care within the va system. We know from research that va care saves lives and we know that treatment works. This is a matter of trying to get more people treated. What were trying to do is to out reach to veterans that arent getting access to care. But we cant help those that we dont see. This is where we are extending our help into the community to work with community partners. Were doing more to reach veterans than ever before. As secretary, i have authorized that we do start providing emergency Mental Health services to those who were other than honorably discharged. We can do more with your help. We have asked every Medical Center this month to sign a suicide declaration pledge. Im pleased that you signed it this morning, mr. Chairman, along with the Ranking Member. When i was out in nevada senator heller also signed it with his community members. So were doing that across the country. Thats a pledge of specific action steps that we want leadership to take to help reduce suicide. We have developed the largest integrated Suicide Prevention network in the country. Our goal is to hire 1,000 more Mental Health professionals. Our crisis line which we established in twerch has now answered more than 3 million calls and dispatched 80,000 ambulances. Were helping a lot of people through that. The Veterans Crisis line number an i encourage everyone to keep this in their phone because you never know is 18002738255. This is clinical work and this is not just a call center. We have expanded teleMental Health. We have 11 hubs throughout the country. In 2006 alone, we had 427,000 teleMental Health encounters. Thats more than ever before. Weve taken from our Research Enterprises reach vet who now predicts who may be at the greatest risk of suicide, up to 80 times the risk of suicide of a regular person. Now we call them to out reach and see what we can do to proactively help. So not waiting until theres a suicide attempt. On september 15th of this month we released state suicide data. Many of you have been referencing that data. But we think thats going to help people design more effective interventions. Weve continued to develop Public Private partnerships because va cant do it alone. This morning i was talking to the Cohen Network as one of those partnerships. We continue to invest in two va center of Excellence Research initiatives to help us understand how to do interventions better and to take a Population Health approach towards reducing suicide. This month as youve said is suicide Prevention Month. Thats our be there campaign where were reaching out to make people aware and try to decrease the stigma of Mental Illness. Ive brought with us our new psa announcement. In the fabric of america, they are the toughest threads, our bravest and most selfless. They raise their hands, stepped forward and served for each other, for you and me. One of the first things they learned is the code that every Service Member lives by, leave no one behind. Some veterans are being left behind. 20 of them take their own lives every day. Why . Its not simple. It never is. What matters is that were there for them, just like they were there for us. A handshake, a phone call, a simple gesture make a big difference to a veteran in crisis. Those are three things that i think we could use your help on. And third, we need more research in this. I think many of you have identified, there are no blood tests. The biomarkers. We need Better Research in genomics. Thank you for holding this today and id be glad to take any questions, along with dr. Carroll. Senator manchin we recognize first. I cant thank you enough. Im so sorry. I have a hard 11 30 with about 100 children here but i wanted to ask a couple questions. I know youre aware and there are more and more stories in the news about veteran suicides, the most alarming one is theyre doing it at parking lots. We just had one in clarksburg. Its becoming more of an occurrence than we ever thought it would be. I dont know if you all have taken steps, if its been a high enough level that its a problem in the country. Believe me, were extremely aware. Youre right, what were seeing is people are coming onto va property. We are doing a number of things. Part of these declarations that every one of our facility leadership are signing ten action steps. One is to train every one of our Staff Members in Suicide Prevention. A v can i ask this question . Yes. What im concerned about and its alarming. Its not well publicized, as you know. Its becoming more and more and what happens in a small rural state such as West Virginia that happens in the parking lot at the va. We have a lot of veterans in our state. Im concerned about this maybe being taken inside the hospital to where its more than just that person doing harm to themselves, because they need help. I dont know how you secure that . Are we securing the hospitals . We all have to come through to come on va property, we have to have a stop. Theres a checkpoint. Right. I would hope you would consider that. I want to go to another question if i can. Y im talking about in rural West Virginia, rural montana. We had one vacancy for a psychiatrist in West Virginia that was posted in january 2016 we had another one posted since october 20, 2016. Another vacancy just posted within the last five or six months and theres vacancies for Mental Health counselors at beck ley. Can you tell me of the people that have been hired, what is the ratio between rural and urban . Its probably a lot easier to get somebody in an urban area than rural . I think youre right. Martinsburg is actually believe it or not a success story. A year and a half ago i was really concerned about their staffing levels. Theyve done a great job of bringing people on. But in general it is harder to recruit in rural areas. In our urban areas is where were establishing our 11 teleMental Health hubs. This is where we want to see expanded graduate medical Education Programs in those rural areas. Do you have a Loan Forgiveness Program . We do. Its a very effective program. In the clay hunt program youve asked us to do that more but you didnt appropriate money for us so were trying to find the additional dollars that would be in july of 18. I want to thank you all so much for the job youre doing. Thank you. Were going to go to senator moran and murray and rounds and tester and ill finish up. Thank you very much. Secretary, thank you for joining us this morning on a hugely significant and timely topic. First of all, i want to highlight the hearing that our appropriations subcommittee had in april on this topic, but i want to remind you, mr. Secretary and i understand that senator murray has a question for you about va followthrough on a commitment that was made at that hearing. It was committed by the va that we would getmo monthly reports regard to your efforts to comply with the secretary generals recommendations and failures at the va in regard to suicide and we have not received those reports on a monthly basis. Ill defer to senator murray but i would join her in her request that what was promised would actually be followed through on. Let me then talk about another topic that senator tester and i have worked on. Weve been trying for a long time and in fact, in 2010, now seven years ago, gave the va the authority to hire marriage and family therapists and licensed professional health counselors. The results of that authority have not resulted in any significant hiring of either one of those professionals. I would guess that senator tester and i are interested in this reason for the scarcity of professionals generally but especially as you were indicating in rural communities. And so we have sought and provided Congressional Authority for the va to hire. You indicate youre in the process of hiring a thousand additional professionals. But i would tell you after seven years those two categories only account for 2 of the Mental Health work force at the department of veterans affairs. Senator tester and i have a letter to you in this regard that was sent to you just a few days ago, but in this hiring would you again commit to filling these positions with those professionals, something that has not happened . And if so, how many of those are going to be what would you prediction be would fit an mfp or an lpmhc and would you provide me with those numbers as you fill those positions . And i assume there will be a priority given in regard to places that are hard to recruit professionals. I also know that you have hiring authorities that are difficult. I dont know what youre expedited hiring authorities are. What are they . What do you have at your dispose disposeal and do they apply to Mental Health professionals . Weve noticed so many times the things that are having to be posted dont result in any kind of Quick Response for hiring at the va. We discussed this topic with dr. Stephanie davis who testified. Shes at the eastern part of kansas. She testified before the subcommittee in april. Johns are posted on usajobs. Com where applications can linger for four or five months. People find other jobs in the meantime and it becomes even more impossible to recruit and retain. We know that positions set vacant for months or even years during the federal hiring mechanism. What can you do to get that process expedited . And then finally, mr. Secretary, i wanted to tell you i was just at the phoenix va where i saw one of the pilot programs under clay hunt act. Theyre called be connected. I was impressed. What this is about is having those who have similar circumstances who have served our country who are veterans themselves who have had ptsd and other problems as the counselors for those who are calling the number. Id be interested in knowing what the va is doing to support be connected and are there plans to expand that program elsewhere . A lot of questions, so im going to go really quickly and anything that i dont do an adequate job on, i will follow up. First of all, on the issue you talked about us not providing time timely followup. Thats unacceptable. If we say were going to commit to something, my expectation is we commit to it. I appreciate you letting me know about it. I can assure you my staff will be knowing about that. But we will do better and thats just not the way i want the department run. We will make sure that you get that. On the marriage and Mental Health counselors, ill look forward to the letter. I am aware that we continually hear about vas strictness on our accreditation issue. This is particularly a training issue since there are two accreditation programs. We are committed to bringing on marriage and family therapists. If dr. Carroll has any specific information on numbers, i would defer to him in a second. On the issue of hiring, its the single most challenging thing that i know of in va. It shouldnt be that hard to get people on board. In the accountability act that we passed together not too long ago, you gave direct hiring authority to Medical Center directors. That is really helpful to us. It allows us to skip over a lot of the red tape. I want that authority for all of our Critical Health professionals. I would urge us to Work Together on that. Its just too hard to get people hired into the va. Do you have the authority to do what you need to do . Only under Medical Center directors. So if we could work on expanding that, id love to target it for Mental Health, but we have other health needs as well. And on the be connected program, peer support is something we are really committed to. We think this works. Particularly for veterans who understand what theyve gone through. Thank you for your visit. Thank you for mentioning that. Thats something were going full force on. Do you have other plans for that program elsewhere . Yes. We already have about 1100 peer support counselors. Much of our vet center model is based on that model. We know it works. Thank you. Since the resident state of senator moran is kansas that the third Mental Health Hotline Center is set up in topeka, kansas, if im not mistaken. Youre correct. It really is such an important topic and able to listen to much of the first panel from my office in between meetings and it really was good. I appreciate it. Thank you for your testimony. Thank you for saying this is a number one priority, because it is. But i do remain deeply troubled by the igs findings from may 2017 that va is not complying with a number of policies including 18 of facilities not meeting their requirement for five out reach activities each month, 11 of high risk patients medical records did not have a Suicide Prevention safety plan. And for 20 of inpatients and 10 of outpatients no documentation the patient was provided a copy of the safety plan. Coordination of care for patients at high risk of suicide and critical improvements to follow up for high risk patients after discharge. 16 of nonclinical employees did not receive Suicide Prevention training and more than 45 of clinicians did not complete suicide training within the first 90 days. Anything less than 100 isnt acceptable. When will all the igs recommendations be fully implements . First of all, this is exactly why the ig is valuable, pointing this out. I have no other mechanism to get data that comprehensive. We have committed to addressing the ig concerns. The reason we have made Suicide Prevention our number one priority is to fix those issues. Weve committed to training. So over this year look, 100 is the right goal, but i cant tell you exactly what date were going to reach that, but were going to be working really hard to get as close to that as possible as quickly as possible. Back in april i asked for monthly updates until all of the problems at the crisis line are resolved. Va has not done that and that is really unacceptable. I want a commitment to you today that we will get those updates starting right now. I think you will get that commitment, yes. We intend to see that happen. Let me ask you about Women Veterans. I am really disturbed in the increase in suicide rate among our Women Veterans. Between 2001 and 2014 the rate of suicide for Women Veterans who do not use va care increased by 98 . Ive heard from Women Veterans many times that they dont think of themselves as veterans and they dont feel welcome at va facilities. It is a significant problem actually that the Rand Corporation testified in april as well. But this increase in suicide is the most important reason yet that i believe va has to redouble its efforts to reach out to women and get them into care. I wanted to ask you what are we doing to address that. Well, you gave a really important statistic, which is that over the last 15 years between 2001 and 2014 those women that did not receive care in the va, that the rate of suicide went up by an extraordinary number. You said 98 . Those that did use the va, we actually saw a decrease, a decrease in suicide rates over that 15 year period of 2. 6 . We know that getting care and teex care ma access to care makes a difference and saves lives. The issue about making the va more welcoming to women is a critical issue. Its a cultural issue. Of course, we are absolutely, as this is our number wone priorit, committed to putting more resources into this. This is something we have to keep working on, because if a woman doesnt consider herself as a veteran, she doesnt think about going to the va. If she is not welcome at the va or doesnt feel that the veteran facility is welcoming to her, she wont go. If she has other issues, child care, work, its doubly hard. This is not an easy problem to solve but we really have to put hearts, minds, resources and as a country recognize Women Veterans. I agree. I just have a couple seconds left. I wanted to the i can ask about the vas reach initiative. Models to identify veterans who may be at risk of suicide. I want you to tell us how that model works. Also 14 of the veterans who die by suicide do not come to the va for care. That is a Big Data Analytic Research project. I said its time to stop researching it and start putting it into practice. Senator testers point about every day we delay theres going to be more deaths. So we have moved it into the clinical setting. Are you with me . Yeah, i am. So they find among this population that the increase for whites is largely accounted for by drug and alcohol poisoning, suicide, chronic Liver Disease and cirrhosis. Although all education groups say increases from suicide and poisoning, and i could go on. I guess what im trying to figure out is how much of this is unique for the v. A. Relative to this study as opposed to its just kind of what were seeing in society . Right, well, first of all, your questions before were excellent. We do not adjust by socioeconomic status because the way we collect the data off the National Data death index and from the cdc data and v. A. Data doesnt have a socioeconomic let me ask because as a physician when i used to practice, i would find that usually folks who were well to do didnt go to the v. A. For their health care. Our eligible doesnt allow unless theyre Service Connected. Even though the Service Connected who had more money, they preferred a different facility, for whatever reason. Do you know the mean socioeconomic class of your typical v. A. Attendee versus the general population . Were definitely more a safety net organization. By proxy, we can assume that you have a higher death rate among those being seen that that would probably reflect your overall population. My back yground is not helptology so im going to give you my best educated guess. There is a socioeconomic status component that i think youre identifying, but the veteran population is more than that. You wouldnt see as large a difference. I think its both in there. Again, if its merely reflective of the larger population, that is tragic, but the v. A. Represents the hope. Right. If it is no, being a veteran in the v. A. System is an additional risk factor, thats something to be identified and corrected. Well get that to our Health Services Research Team to see if we can do that. We published 75 articles on suicide and Suicide Prevention last year, and we have a good team on this that i think could maybe tease some of that out. Let me ask, my staff has given me but i have not yet comprehended it. The Mental Health composite summary. I have stats for louisiana. I know you have done that analysis. Is there a difference in suicide rates associated with different facilities . Again, hopefully correcting for that each population is the same but im assuming its a roughly homogeneous population. I have seen the analysis by state, not by facility. Dr. Carroll, have you seen that . The analysis is by state. The veteran population is not homogeneous from one state to the other, nor is the general population. There are state differences in the population, both at large and for veterans. I accept that. But probably broadly, louisiana is a higher africanamerican population, and some states have a higher hispanic. Theres going to be that broad demographic. But dr. Casey pointed out its among nonhispanic whites were seeing a bump in the general population. Have you done a very rough, as i was told on the previous panel, we have it for age and gender. Do we have any sort of rough estimate on that. Those analyses are ongoing. Let me ask as well because youre sending out this data, and thank you very much, looking at specific facilities. Im presuming that most vets, not all, but most vets have a facility of choice. Yes. Is your analysis going to include the rate of corrective for all these other factors, how each specific facility is doing . Senator murray pointed out were not getting 100 of these being passed out, but i suspect that would vary from facility to facility as well. Yeah. I think the type of statistics that senator murray was talking about, about compliance with screening absolutely is done, not only at the facility level but by the specific provider. Oh, yes. You have Electronic Medical record data on that. The broader statistics which include the National Death index and other things may be harder to do by facility, but you could look by state. Absolutely. I think we need to know, is this a v. A. Issue or does it reflect broader society. Its a v. A. Issue, we need to give you tools. Does that make sense . Right. You do know about the difference between veterans who are getting care in the v. A. And not in the v. A. I saw that, and you want to correct for that, but you mentioned your safety net, and we suspect that, my suspicion is in some places youre serving as a safety net, and some in places theres inadequacy, which case we need to identify and address it. If you need tools, we have to give them to you. I yield back. Thank you. And thanks, Ranking Member, for yielding. I want to follow up on senator murray and senator cassidy talked about the suicide report. I first thank you for being here and thanks to dr. Carroll, too. I dont really understand my state, 244 veterans took their lives and took their own lives in 2014. I want to talk about them and the thousands around the country. Im not really clear on why you would release that statebystate report on a friday afternoon at 5 00. Thats not really my question. I dont understand why you would do that. Talk to me about how you share this data statebystate, how you share it with veterans, with Medical Centers, with Community Providers, with academia who address what you call the national Public Health issue. Yeah. Weve this analysis, which was released on september 15th, friday, at 5 00, is really the first time that weve released that type of specific data. So were actively trying to get that out and to share it with the groups that you mentioned. There was no attempt to downplay this issue. If there was, it was a bad strategy because what were seeing is all around the country, that data getting out there and being picked up buthe press, being discussed in forums. This is exactly what we want to have happen, and were actively disseminating it. If you dont know your data, i want every Medical Center director knowing what their number is, how many veterans they lost. You cant design as effective an intervention. That means not just a patient from that Medical Center. It means population. Never got into the v. A. System in franklin county. Thats the populations. Talk, new psa employees no vet behind. 14 of 20 vets who take their lives each day dont use v. A. Care. Talk to us about the reach vet initiative. What metrics you have in place to see how its working, what your what the process to get those 14 who then wont take their lives if they get v. A. Care, talk that through. Yeah. So the reach vet program is not for is not for those that arent using v. A. Its for those who are using v. A. That we know are at high risk. The 14 that arent using v. A. , thats where were beginning to start tackling it through other strategies. Letting other than honorable have emergency Mental Health is a strategy that will bring some of those 14 into the v. A. For others that arent eligible or choose not to go to the v. A. , were working with community partners, and were working with Veterans Service organizations. Were working with the churches and the synagogues to make sure that they understand that they have a responsibility in this. The psa message essentially is Suicide Prevention is everybodys business. And we need Family Members, friends, coworkers, to be able to identify people at risk to get them help, whether its at the v. A. Or outside the v. A. Thank you. Thank you, mr. Chairman. Thank you for your work on this issue. You heard a number of my questions earlier today. I did. About that difference between the veterans who have used the v. A. And the veterans who have not done so. I know you have been asked a number of questions about that issue so far. I want to focus on the less than Honorable Discharge group. Do you have any thoughts about how that cohort can be better accessed and how they can be encouraged to come forward, because i think that the knowledge about them is also lacking . Yeah. Well, quite frankly, i did what i could. It was one of the first things i did as secretary, just to use the authorities i had to offer emergency Mental Health services. I thought it was wrong that we were not providing access and were letting them out there, and they are at higher risk for suicide as Homeless Veterans are at higher risk. But i did as much as i can. Now, i actually need your help. This, were going to need legislative changes to allow us to offer other than honorable other than Honorable Discharge people to be able to access our full array of Mental Health and physical services. All that i was able to do is offer 90 days of emergency treatment. And then im trying to find them other places to get care, working in the community. Were going to do everything we can, but it is not the ideal approach. We could use your help in this, senator. Well, i would like to work with you. I have other questions. Sure. I would hope we can pursue this. As to all of the veterans who right now are, through no fault of their own, perhaps, not part of the v. A. Yeah. I know youve been asked about the Suicide Prevention act. I would also like to follow up on that, particularly as to the funding that is necessary. The president has signed a number of measures dealing with veterans issues. Those pieces of legislation have been long in the works. And we have devoted a lot of time and attention to them. I hope that his apparent commitment to those issues will translate into funding, which is really the test. Its fine to wield a pen on measures that were started well before his presidency. Now its a test of his commitment. And i think that applies to issues like the Veterans Crisis line, the Suicide Prevention measure, and i would like to, again, ask you about Women Veterans. And what expanded or enhanced efforts you contemplate involving Women Veterans. Well, first of all, thank you for highlighting, i think, all of these issues that are important. The president s budget, the requested budget actually has increased funding for both Mental Health care and Womens Health care issues. Both critically important. So i think that he does share that commitment that you have to seeing us do better in these areas. Is that amount of money, in urview, sufficient . I was very pleased with the president s budget. I think that many of the issues that were dealing with werent Financial Issues solely, but in areas that we have to do better in, im not only seeking additional funds, as we saw in the president s budget, but im actually moving current budget funds into higher priority areas. And so i do think that we have sufficient resources this next year, should the president s budget get approved. I would be remissed if i didnt ask you about the west haven veterans facility. We have talked about it. It was built in the 1950s. Its out of date structurally. It needs more than just rehabilitation. It really needs rebuilding. And i wonder where it stands on the list of priorities and whether the president s budget is sufficient to cover the Capital Improvements there and elsewhere. As you know, you and i stood outside that building, and i think your assessment is jenress. I trained at the west haven v. A. , and i dont think its changed too much since i was there. We are still undercapitalized in the v. A. I think realistically, we can expect to take decades of essentially underfunding and fix it all at once. So we are putting more funds. We have requested more funds into the modernization of v. A. , i have announced i want to dispose of 1100 facilities that arent being utilized well by veterans to put back into facilities that are busy like the west haven v. A. I dont have a specific number of where the projects are, but certainly, i am going to support fixing the west haven v. A. And other facilities that arent modernized, and part of that is were going to have to redo our matrix on how we make capital decisions because right now, i will tell you, the number one weighted factor and where the money goes is the seismic improvements. While thats really important, im not going to say that thats not critical, youre not on a fault line. And it puts facilities like west haven at a disadvantage. Were going to be looking at that. I hope i can be generous in pushing west haven to a higher level on the list, as you noted. I was being generous. It has really changed little, if at all. There are some cosmetic improvements, but you well know the level of dissatisfaction that exists about it. And i would add that it is dissatisfaction with the structure and the capital facility not with the staff. I agree. I want to just give a shoutout to the very dedicated men and women who work for the v. A. In connecticut. And i have no authority to speak on behalf of veterans in connecticut, but generally, i have gone to high level of approval in satisfaction. So they deserve our thanks, and they work under conditions that should be better for them and for our veterans. Im sure they will appreciate both of those sentiments. And i would like to invite you to come visit, again, and be at that facility with me again. And i want to thank you for that. I do have a visit scheduled. Ill let you know. Okay. When that is so we can get there together. Wonderful, and i thank you, by the way, in the meantime for the work being done on the wifi internet connections, which is very important there and at v. A. Facilities around the country. Exactly. Thank you. I want to add to your answer a second ago. If im wrong, i want you to tell me. As you go through your 1,100 evaluation of underutilized facilities to invest in places that need more help, youre going to consider rural locations, rural states, populations, things of that matter so north dakota and montana and things with a light population dont lose out on a statistic in terms of the availability of Clinic Association . What i announced is that, first of all, i share the sentiment that we dont want policy that discriminates against locations because the rural or because theyre not on seismic faultlines. But what i announced previously was that in the state home money distribution, that the rural areas were never getting from the bottom of the list, so i committed to relooking at those criteria because the state home grant moneys really were going only to very small numbers of states, essentially. But i do want to make sure that we are modernizing the facilities in an equal way across the country. I want the Ranking Member to make sure we knew were looking after our interests as well. Senator tillis. Why youre such a good chair, mr. Chair. I was going to end with a capital project, but let me go to that because i think this is critically important. You have said that you believe, i believe the president has a real commitment to veterans and accelerating some things and frankly didnt move as quickly as i would have liked for them to have in the past couple of years. But i have the same view in my role in Senate Armed Services. Were always going to have fewer resources than you want. Right. And shame on any member of congress who advocates for moving something up ahead of line where the data doesnt say its the best way to provide care to the communities that need it. Im in North Carolina. Im in a 50 urban, 50 rural state with over 1 million veterans. 10 of my population. If you told me montana is where the resources need to go to serve that population, thats where i want it to go. Along with that, when youre taking a look at optimizing capital projects, shame on any member who tries to come up with a statutory protection for something that you dont think is in the interest of supporting the veterans. I every once in a while call up a v. A. Facility the night before i happen to be in town. Want to stop by and see them. I said this is not a surprise visit. I just want to talk to you all. I stopped in one a year or so ago who said they made a proposal to consolidate two operations that were only about 40 minutes apart. They thought they could provide better care to the veterans by consolidating the resources and getting more leverage, but we had a member of Congress Stop that because it happened to affect 75 jobs in their district. Thats not the way we should think if were going to get out of the way and let you support veterans in a more appropriate manner. I need to make sure i have your commitment and any time you see us doing something thats at odds what is your best professional judgment is getting the resources to the communities who need it most and making optimal the resources that were given you, i want to know who that is because i think they should be held accountable. Not on the Electronic Medical records. I want to go back to the questions i asked the first panel. Actually, i want to thank you for being here because i was rushing in and i mistakenly thought you were in the first panel, but it doesnt surprise me you and your team were here to hear that testimony. I thank you for that commitment. I like the decision that you made for the baseline system, because i think its an accelerator between dod and v. A. , but similar to the question i asked when you were here last, we know we got over 120 instances that have to be consolidated within v. A. , but even more importantly, we have nonv. A. Care providers out there, choice providers out there. I believe that as you get further into the Implementation Plan that we discussed in my office, that youre going to identify that you need other layers in the Technology Stack to make sure that we know how prescriptions are being dispensed, whether theres any dangerous interactions, other indicators you can use to make that a more productive experience for the provider and for the patient. And so have you gotten to a point now where youre thinking through how as youre looking at your implementation priorities and your broader transformation plan, the remainder of the stack, or we used to call it gluwear, or buying and configuring tools youre going to need to flesh out that Technology Stack . Weve gotten to essentially the principles that you have talked about, saying a system thats going to work into the future is going to have to have the components that frankly you have done a good job of outlining. We havent gotten to defining which specific tools they are yet and how were going to meet those needs, as we talked about the days of v. A. Being a Software Developer are over, and were going to be looking at off the shelf current technologies. But theres going to be a lot more definition on that. I think yesterday we wreleased to congress, to you, the 30day notice of an award of a contract. So we are keeping on the timeline that we talked about. Were marching forward. We have the principles. I have some updates to share with you on the strategic i. T. Plan, because i think we are making a lot of progress with that. We are going to announce that we will in this i. T. Conversion with obviously your support, we will be sunsetting 80 of the projects that were currently under development, so this will be i think not only the right thing for clinical care, but also the right thing for taxpayers. Thats great to hear. Im going to hold my time because i guess im the last member to speak. But we do have a number of questions for the record on Suicide Prevention issue. We are, i took note in the first panel, and i have asked my staff to get with the Senate Armed Services staff because i would like to have a Committee Hearing at the subcommittee level to talk about traumatic brain injury, ptsd, and things that were doing to do a better job of detecting and treating it, but i would like to add a second panel that then talks about the veterans who may actually first off, how do we track those who get an Honorable Discharge and make sure that were trying to anticipate or provide interventions for ones who may be at risk of suicide, and then for the ones who have other than Honorable Discharge, what are we doing to make their experience when they were in the military instructive to any decision about what category of discharge they get, and then finally, we have to come back to the v. A. And get your advice on how we do that for those who have already received that paper and they need care. And thank you for pushing the envelope. And i heard you loud and clear, its time for congress to give you more tools so you can provide more veterans with care. Thank you. Thank you, mr. Chair. Senator tillis, are you on the way out the door . You have five minutes. I want to ask you a favor, i have to leave, and senator tester has questions he wants to ask and i dont want to cut him off. I have one i want to be sure is for the record. Yo you adopt the same software being used by dod. Thats a huge step forward. Does that merger also allow you access to the same information dod has regarding the wounded warrian transition units . Yes. Our warriors when they leave the battlefield or leave deployment in battlefield areas, theyre asked questions on the computer, answer by computer. It doesnt have a statement. Theyre answering a computer question. There are questions that give indicators of where there may be somebody at risk for suicide. So you have Interoperable Software one day soon. Well also have interoperability access to that information. There is certainly some exceptions with dod. One of the things i just learned recently, i dont know if you know this, the coast guard doesnt have wasnt in their contract, so were going to have to figure out a way to be interoperable with them or get them into this. So theres some small exceptions and were working through those. Our relationship with dod is extremely cooperative on this project. I think were helping them in their implementation. Theyre certainly helping us. But those types of data sources are extremely valuable to us. Youre to be commended for that move. Im going to turn it over to the Ranking Member and ask senator tillis to adjourn the meeting. Thank you, mr. Chairman. Thank you, mr. Chairman. I want to thank you fellows for being here as well as the first panel. I just want to touch on brak really quick because i think theres some opportunities to get rid of some facilities that arent being used. You would agree manpower and recruitment of manpower is a continuing challenge, wouldnt you . Absolutely. So i would just say, as we look for ways to save money and commonsense ways, what im really concerned of, and i know youre not a part of this. If you are, let me know. That they will come in and potentially, if we do it in congress or if you do it administrati administratively, do a brakc, and they say montana, they havent had a doc in years. We say the vets arent using this and close it down. Same thing could be said for senator rounds of south dakota. If Something Like that were to happen, i guarantee there would be a bipartisan explosion on this committee, which wouldnt be a good thing. I just bring that to your attention. Im all for making sure that youre getting rid of properties you dont use anymore, and have outlived their usefulness and utilizing the dollars. Thats a Good Government thing and i applaud those efforts. When we get into the because im going to tell you, i know there are some people who want to do a fullblown brack, and im going to tell you some of the metrics arent going to speak well. Not because these arent good facilities, because they havent been staffed. I just want to bring that up. In your testimony, you said that Suicide Prevention was the top priority. Mmhmm. You also mentioned that v. A. Has integrated Mental Health services into the primary care at v. A. Centers and at cbox. Tell me what that means in montana. Well, what it means is that v. A. By far is leading the strategy across the country, where if youre in your primary care office, you dont have to say i am i have been given a number to go and to call for a Mental Health appointment and then go down the street to the Mental Health department. You get that Behavioral Health care as part of your primary care office experience. How are you going to i agree. Its about destigmatization. How are you going to do it when you have to have somebody there that knows the issue, right . You have to have the Mental Health professionals with your primary care people. Okay. Colocated. In a small population state like montana, were about 20 short right now. Yeah. I mean, the best laid plans without the people infrastructure blow it. It gets back to what you were saying. We have a manpower issue. Its not and its geographically distinct, particularly in areas that dont have a lot of medical schools and other places with untrained professionals. So senator moran talked about other opportunities out there that could get us besides psychiatrists and psychologists, other folks who could help. Is that proceeding . Is it proceeding well . And are we making some inroads . Im going to tell you that we have talked about a lot of metrics today, about what population is committing suicide and what altitude. We have to get our arms around the whole baby before we can even get to a point where were talking about well, look. No other Health System im aware of has Suicide Prevention coordinators. Thats a v. A. Strategy that i think is super effective. Were using peer support specialists in a way that no other Health System is using. And of course, were trying to hire traditional Mental Health professionals, lice jsed social workers, psychologists and psychiatrists. Do you have a comment on the marriage therapists and family therapists . Were encouraging strongly as we can facilities to hire them. That is part of their within their purview. The other thing were doing, to your question about primary care, Mental Health integration, is using teleMental Health. Using our teleMental Health system to provide providers in places where they may not be able to hire a Mental Health professional. Can you tell me, and cbox overall, do they all have tele Health Capabilities . Not all of them. We list them on our website, which ones do. Certainly, the rural ones will be much more likely to have it than you would have in new york city. Really . Right. But one of the cool things, i dont know if you have ever seen it, that just amazes me, you go into a primary care office in a Medical Center, and right there is a digital display that if the primary care doctor wants to dial in a psyologist or psychiatrist, they can do it right from their office and the patient is there. I dont see that in many places in the private sector. So thats that integration you were talking about. Thats good. I want to go back to manpower for just a second. Mmhmm. Earlier in the year, you testified that you were going to try to get 1,000 additional Mental Health providers this year. Mmhmm. Your testimony today says that you have hired over 600 new Mental Health care providers. Im not going to ask what the difference between additional and new are. But has there been a net increase in the number of v. A. Mental Health Clinicians . You just asked it, then. And the answer is no. The 623 is just keeping us even. We are not succeeding at that 1,000 new professionals. I need help in doing that. Doctor. Yes. What do we need to do . What we need to do is to, a, give us more direct hiring authority. Just like you did in the accountable act for my Medical Center directors. Make it easier for me to hire. And we talked about the fact that our recruitment and retention dollars were actually cut in half. That was shortsighted, quite frankly. We need the tools that the private sector has to be able to recruit the very best Health Care Professionals. Of course, areas of tackling this, dont tie one of my hands behind my back. I want to be clear. Did we cut your Recruitment Retention dollars . To pay for the legislation, yes, sir. Yes. Keep going. So a competitive process so i can hire quicker. Recruitment dollars. Recruitment dollars and the flexibility to be able to help expand training. Those are the three areas that would really make a difference. Look, theres a National Shortage here, so you know, i think we all worry about not just whats happening in v. A. But everywhere. These are all important strategies, particularly the training one. Yeah. Ill just make one side comment. You know this better than i do. Youre right, it is a national problem. But with veterans, we made a promise to them. Yes. So we cant have a bunch of excuses. We have to have more solutions. Right. Appreciate you guys being here. Thank you. Thank you. On the last point, were about to adjourn. Im not going to ask other questions although i have them for the record. I remember this discussion within secretary mcdonald, i think there was a series of news stories that some of our members got tempted into amplifying that had to do with training and Retention Programs that you thought were critically important. And i think what we need to do is understand, if youre going to make this an attractive place for professionals to come to, then you better have professional development and a Retention Program similar to the private sector. And when you see some of the dollars that you were spending on training, im sure i could find something that was not a good idea, but i saw the numbers that the v. A. Was spending on a per employee basis, and it was pennies on the dollar compared to what i would have spent at a partner at price waterhouse. Youre never going to get to that ratio, but we have to not talk out of both sides of the mouth. On the one hand saying we need to give you recruiting, and then we want to micromanage how you spend it. I have never been the head of a Major Health Care system before. You have. Now youre the head of one of the biggest in the world. I trust you to make a decision about how you have therapists and doctors and technicians and other people you want to attract and have a Value Proposition so youre getting your fair share of the best resources out there in the private sector. Thats another one where when we hear us say one thing and do another thing here, please give me your commitment that youll say thats not a good idea. Thank you. Were going to adjourn the Committee Hearing. And were going to leave the record open for one week for additional questions. Its always a pleasure to see the leadership from the v. A. This meeting is adjourned. Congressional republicans released their tax reform plan to members today. And then to the public. According to congressional leaders, their plan would lower rates for individuals and families, double the standard deduction, and enhance the child tax credit. Eliminate loopholes for the wealthy, and repeal the inheritance tax, called a death tax. And the alternative minimum tax. There are a number of other provisions which will be outlined by the predlater today. Senator Bernie Sanders had this response. It is particularly obscene for trump to repeal the estate tax which would provide a 269 billion tax break to the top. 2 . No family will have to pay the death tax. Were going to repeal the death tax. The death tax. The death tax. A death tax. A death tax. Death tax for americans. Its been called the estate tax forever. When i say the word estate, you think wealth. The death tax is the renaming of the estate tax. The death tax. The death tax. The death tax. People think youre taxed because you die. That changed the entire dynamic of that. 99. 8 of americans would not get a nickel in tax breaks by the repeal of the estate tax. Just plain wrong. 353 billion in tax breaks to the very richest people in the country. No one wants to see their children have to sell the Family Business to pay an unfair tax. Silly to say that hes probillionaire. Thats what happens when you repeal the estate tax. I want you to think about this. American workers have paid taxes their whole lives. They should not be taxed again at death. This is really about a middleincome tax cut. Theres nothing in life thats truly free. Somebodys going to pay for it. Talk about a rigged economy. My friends, this is what were talking about. Health and Senate Republicans also put together videos to promote the tax plan. They took different approaches and were going to show you both now. Live coverage now as we stand by for a News Conference with minority leader Chuck Schumer and senator ron wyden on the newly released gop tax plan. Democratic senator schumer says President Trumps plan only gives crumbs to the middle class while the wealthy would reap a windfall. President donald trump has two red lines he refuses to cross on overhauling taxes. The corporate rate must be cut to 20 and the savings must go to the middle class. That word comes from gary cohn. He says any tax overhaul signed by the president needs to include these two elements. Were standing by for live coverage of the democratic reaction to the newly released gop tax plan. In the meantime, well show you Senate Majority leader Mitch Mcconnells opening remarks on the senate floor this morning, talking about the republican tax reform plan. I look forward to joining members of the Senate Finance committee, the house ways and means committee, and other congressional leaders in unveiling a unified framework for fixing our nations broken tax code. Its an idea that can bring much needed relief to middleclass families and Small Businesses and help keep more jobs right here in america. Its a result of a lot of hard work and input from members, committees, staffs, and the administration, to name a few. I want to thank them again for their continued diligence on behalf of our country. This framework is focused on supporting american jobs, on making taxes fairer, and on growing families paychecks. Its a refreshing change from our current outdated tax code which for too long hasnt worked for Many Americans. The current code forces individuals, families, and Small Businesses to navigate a web of schedules, deductions, and penalties. Rates are too high. Incentives often make little to no sense. Some actually encourage companies to ship american jobs overseas. Moreover, for eight years under the obama administration, our economy grew at a sluggish rate, never living up to its real potential. Too Many Americans struggle to get ahead. Many living paycheck to paycheck. Its time for a significant change in favor of families and jobs. This is our once in a Generation Opportunity to fundamentally rethink our tax code. We can unleash the economy, promoting growth, attracting jobs, and improving american competitiveness in the global market, instead of sending jobs overseas, we can modernize our tax code to help bring strong investment and goodpaying jobs home and keep them here. Through this framework, we can lower taxes for individuals and families so hardworking americans are able to keep more of their hardearned money. Later this afternoon, President Trump will bring our shared vision of tax reform to the people of indiana and to americans more broadly. He will explain his support for putting americans across the country on a more level Playing Field because when they are okay. Wheres ron . Good afternoon. Yes, it is afternoon. I want to thank our great Ranking Member of the finance committee, senator widen, for being here with us today. Well, theres a lot to unpack in this outline,o