Transcripts For CSPAN3 Politics And Public Policy Today 20151229

Infrastructure to deliver that care. Within the v. A. Within the v. A. But where we cant justify that business decision we need to be outsourcing. And just one more thing that follows up with that. In another year you guys are probably going to be gone with the new administration. I hope not, i hope yall stay but youre probably going to be gone. Are you laying into process so that whoever takes your place assuming that youre not brought back that the transition would be seamless and the justification to keep going . Were absolutely looking at ways that we can institutionalize what were talking about doing. Thats a better word. And i would say that one of the important roles that this committee can play is to be a stalwart of continuity about some of these operational things. Youve had six or seven different outsourcing. How to make sure theres a direct connection from v. A. And Community Providers and from the business side having one pot of money for care. I think what we tried to do in the plan is create these Eligibility Criteria that focus into these three big buckets, one is geography, one is wait time, one is availability of services. So for the most part a lot of the veterans using project arch will be able to continue to use Community Care through one of those three mechanisms. There may be some folks that would have to change providers. In those circumstances we want to create a transition plan to make sure theres a warm handoff as needed. Thats good. I want to point out the kansas example, if you dont have people on the ground that know what you guys want, it aint gonna happen. So i hope that communication filters all the way through middle management to the ground because youve got great folks on the ground. The last thing if i might, mr. Chairman, the last thing im going to say is that, sloan, youre right next to the big guy. We had a scheduling hearing here a month or two ago, on scheduling within the v. A. They said the v. A. Is working on a new scheduling program. Is that correct . Yes, we are. How much is that baby going to cost . In fact, there are two or three efforts under way. There are some apps. Were going to be able within six months, maybe less, to provide veterans the ability to schedule an appointment for primary Care Mental Health care. And that was an offtheshelf program. Through a mobile app developed inside v. A. The other thing the second leg of this effort is what we call vista scheduling enhancement where weve taken and modified the actually put a graphical user interface on top of the old 1980sera scheduling system so it looks like a 21st century app and works like one and thats happening within the next six months or so. The longer term scheduling process is this comprehensive replacement and were going to do that in a very deliberate kind of way. Because were about to deliver the field a substantial improvement in scheduling functionality. Folks in the field that have seen this thing working are awestruck. They cant believe that weve got Something Like that coming that soon. The comprehensive one . No, this is vista scheduling enhancement with the graphical user interface. So let me just ask you this because the last and good people at the panel but didnt give me much hope. They said that if im a veteran and schedule with the v. A. And its december 1 and i schedule on the 20 and get in on the 20th, theres no wait time but if that appointment was delayed until the 25th of december, thats a fiveday wait time, thats how its valued. Is is that going to zmang thats not real. Well, let me tell you whats real. We want appointment scheduling to be either clinically relevant or we want it relevant to the desires of the veteran. When you measure from what youre describing as the create date, if my doctor tells me im seeing my doctor for a chronic condition and he said i want to see you back in 90 days and we schedule an appointment in 90 days, did i wait 90 days if that are appointment . It was scheduled coincident with the clinically indicated date. If i call in and say i need to come see the dermatologist but im going to be traveling for the next three weeks. When can i get in after that . And we schedule that veteran in 24 days, whats my wait time . Did i wait 24 days far appointment . So what were trying to do is make it either clinically relevant orel havent to when the veteran wanted to be seen so thats where we measure the wait time gap from. There is no relevance versus the create date. The large majority of our appointments are return to clinic appointments so you would see consistently if you were looking at wait time data you would see all kinds of examples of people waiting 120 days or people waiting 60 days, six month, 180 days for an appointment when thats when they were supposed to come in and be seen. Youre right, except for the fact that how the hell do we measure wait times . If im a veteran look, i took my grand daughter to the emergency room the other day, everything worked out fine. Sy spent five nourse that emergency room. They looked at her for 20 minutes of that five hours. I still spent five hours in the emergency room. When that person sets up an appointment, how are we to know which is which, which that person has a pain in his heart and needs to get in today and was put off for three days, youre right, its more critical. But the question is how do you get oversight on it . We publish that data every two weeks. I know but well pick this up off line. The truth is that it doesnt work so good. Thank you. Thank you, senator tester. Senator tester, i never get tired of hearing your questions. You havent been here long enough. [ laughter ] you know, i want to shift gears to really get back to really tap on what senator tester was getting at earlier in terms of institutionalizing this so that were not suddenly restarted in tweech. Yall have said a couple things that give me hope and a couple of things that give me concern and im coming from something that helps large System Company december complex their environmen environment. I use this as an example of its a good short term fix, on the other it adds another layer of complexity. Pig. So youve implemented something that makes it easier in the process of doing that you probably not only aggregate data from other systems, you have another layer of complexity when you get to the ultimate task of replacing so we have to be careful not to go after short term priorities voiced from us or others at the expense of creating a longterm sustainable economically viable fix. Thats more of a direction than i would think that you all would agree with that. I would be fascinated if any of you didnt. We agree wholeheartedly with you. One thing i that i think we need to do, i sometimes think we need to have hearings here where the only thing at the witness stand is a big plate glass mirror. Part of what you need to do the cio of this council is top notch, she has great relevant experience for the job shes been assigned. What you need to do as you go through these buy versus bill decisions is make absolutely certain that youre buying what creates a best practice and not necessarily creating a frankensystem where you start out with a buy, it looks great, then you say this congressional mandate requires this sort of reporting or this other an let i cans capture. This is requested by some senator, requires so many variants, theres no resemblance to the baseline project that you want to maintain. We had a hearing here a couple months ago where senator brown and i have moved a bill thats going to provide a benefit and i think that sloan in your opinion that hearing where i said its a shame that a benefit that over ten years will equate to 6. 2 million. Its going to require 5. 1 million in systems changes before you can start providing the benefit. So sooner or later we need to make sure you all can come back. I want to associate myself with the comments made by most of the members and i share the frustration of senator sullivan. I wont get into the episodic issues with fayetteville or anything else in this hearing. Thats why well have conversations outside of the hearing. There needs to be a cost associated with the shift of priority that comes from the directions youre receiving from this committee. The value provided to the states youre prioritizing like senator sullivans is worth it over the distraction and the diversion of resources. But weve got start getting serious and have everyone understand what the distraction is possibly cost us in terms of shortening the time to benefit for the overall transformation. We also need you all very quickly to articulate in a way we can understand with the time limits that we have in the v. A. Committee why what i may be asking you to do may move us further to the right in getting the transformation done. Sand the way youre going do that is create a plan that we can communicate before in committee on a statebystate basis what the footprint looks like. What is the mix of v. A. , nonv. A. Choice. What is the timeline to benefit. . What are the things we can expect on a fairly immediate basis . So each one of us can feel like we have that information and then we can determine whether or not it needs to be juggled or whether or not its appropriate. Question havent had that and thats one of the reasons why we get more to the episodic discussions that we have in these hearings. But i would encourage you very quickly. The list of legislative changes you mentioned for the 400 million program, to me its disturbing we have to spend 300 million on a portal because these portals are fairly well established. I know we have a hair ball of systems we have to connect them to and thats where most of the costs come from, not the web site. Right. It is. But its disturbing that if we do these shortterm things were adding complexity and time to the longterm integrated solution and we have to reach a point to where all largescale transformation there has to be a freeze but for emergencies so you can start getting to work on what were all wanting here sooner rather than later. I think you need to go back and take a more critical look at the things that youre having to accept as a give than congress has mandated that you believe no longer have a place in the transformed v. A. And it needs to go far beyond what you probably thought about in terms of the enabling legislation for this particular program. If you dont do that then youre building the transformed system on outdated policies that may or may not have ever been appropriate, they just happened to get through congress and you happened to have to live up to them because theyve been mandated to you. So i went get into a lot of questions except to say the reason i have this flavor to my discussion is that ive yet i want to help you establish a plan that transcends your tenure and your positions. That continues to show progress as we get another president. I want to be an add have had a for that advocate for that. We have to have people on the v. A. That puts the mirror back on us that says youre asking me to do something thats shifting me away from the other thing youve asked me to do. If we do that and you put the mirror in, thats our problem. Is if we make the question and you dont reflect back on us, its prour problem and i want to make this our problem so we can help facilitate the transformation last thing ill mention and first off appreciate the secretary and his staff for the update on camp lejeune, im looking forward to getting the Additional Information but thank you for that progress. Its important. I also want to reinforce what senator murray said, any time ive heard it brought up. Ive spoke within hundreds, probably at that this point been in the presence of thousands of veterans over the last 11 months since ive been senator. I have yet to hear a single veteran whos received care from the v. A. Say they want purely a private choice. They want the optimum mix. They want veterans serving veterans. We want the best possible health care. We know we have world class practices out there so we want to make sure the people who come to us and say privatize it all, they have one thing in common theyre not a veteran and i want to listen to the veterans voices and make sure we do a better job of providing the best care for them which includes choice and nonv. A. And includes it in different proportions based on the state. There are seven states who have one of the highest per capita ratios of veterans per population. I have a state that has more veterans than those seven states have total people. We all have unique needs and we sneed to solve them. But i hope you all will go back and come back with a longer list of things saying a part of the complexity in making the buy decision is because youve told me to do things that are not best practice or necessary to produce the best clinical outcomes so relieve me of this burden. If you start doing that, your job will be simpler and what we do for veterans will be better. Thank you, if i may just 15 seconds, i cant tell you how much appreciate that perspect e perspective, the willingness. I like to think that bob and i have done more of that kind of challenging over the last year and a half or so than has been done in a long time but what youre describing is a real paradigm shift for the department and an extraordinary opportunity and well do our best to seize. It thank you. Thank you for your commentary and analysis. Very valuable. In the on sense of the chairman, there is no second round but i have a question and it is in response its a question that follows, in fact, a question that you ask, i think, secretary gibson, of me. As i understand it, my takeaway from this hearing as far as the choice act is that it no longer matters if you live within 40 miles of a facility that doesnt provide the service that you need you qualify to have services at home . No . I thought thats what you said . Response to chairman isaacson. So if you live withinen 25 miles of a c bock, it doesnt provide the services you need, what happens . The definition of cboc, it has to be 25 miles from a facility or cboc that has a primary that provides primary care and Mental Health care, so not the one off facility that has one doctor one day a week or something. If its 25 miles from that, you dont qualify under the gee kwogfy criteria to access care in the communities however you might have a wait time for cardiology and you can access Community Care that way. That cboc may not refer folks to the local medical surgery for neurosurgery and those services are provided by in the community. So its still i think a lot of time people get fixated on the geography. Theres more than one way people can access Community Care. Some of that is through wait times and sometimes they dont offer that service at that local pattern for the Medical Center and cboc and its always provided by to the community. So veterans that live 40 miles or closer to a cboc to a full time physician have a different standard than those who live further than 30 miles, is that true . That is correct. To the veteran who lives 25 miles from the cboc who has a full time position who needs his eyeglasses adjusted, needs to see an optometrist, there is no optics available to cboc would be told to travel the 200 miles to wichita . Thats what weve described in here as the nature of the service. What i read to the chair. Thats in the past i think thats what would happen and what were saying is we dont want that to happen so it makes no sense for us to have a veteran drive 200 miles to get his eyes checked. Thats the kind of care we should be referring into the community under choice. But to be very clear and i think you realize this, if the aperture is opened all the way to 40 miles from where you can get the care, the goes goes through the roof and we simply dont have the resources to be able to deliver that. So thats why were trying to do this in a deliberate kind of fashion. So your plan described to us today is intended to resolve those kinds of issues, no . The way that it resolves those issues is that it allows the local provider physician and veteran to make that determination. So we have the National Criteria of geography, wait time and availability of services but theres this one thing passed by the hill, the unusual and access burden that allows nuance, which is what we need. So when i see patients and determine that that physical therapy you should not be driving 200 miles to get pt after you just had a knee replacement, we can make that decision together and they can access Community Care. Do you make that decision in the in the office. Together today regardless of what happens with your plan for the future . Thats already available to that veteran . It is now based upon what we put in place effective yesterday. So today is a new day . It is a new day. And many of the concerns and complaints ive raised over a lon long period of time in your view are resolved . Because you indicate, you know that where do i get my concern . It comes from case work, what you heard around the table as people bringing us issues and the veteran who lives 25 miles from the cboc who cant get his eyeglasses adjusted because they dont do that was told go 200 miles to wichita and thats the norm of how we relate to veterans, just i checked with my staff. Just this week weve had 10 new cases in kansas related to the choice act and the distance necessary to travel. It is an ongoing would you share those with us so we can do a deep dive and understand thats where we can help identify the defects in the system to understand where things arent working so it would be hugely help. If i can add one other things. Some of the 421 million were requesting has to do with communication, education and training. Theres a big chunk of that. We didnt talk about that today but i think what youre experiencing and what were getting is that if that information flow doesnt occur at every level of the organization theres a problem. So thats some of the costs associated with the plan is to improve those communication channels. Thank you very much. My understanding and ive asked for this information previously, ive learned it exists, theres something called an abandonment rate and thats described to me as those who apply for choice and conclude its not worth it. Those youve perhaps reached out to and they make a request to use choice and conclude to walk away. That could be a good thing because they want to use the v. A. In its traditional sense. It could be a bad thing because theyve hit the brick wall, hit the bur rock six id like to know the abandonment rate. I understand thats a number that you keep. I have no standing to deny the senator another question. Thank you. Thank you chairman moran. The Caring Community and generally nonv. A. Medical services involve payments and there have been various efforts over the years to make sure those payments are validly made. The v. A. Authorized a Recovery Audit Program in the 112th congress, i believe, and the Inspector General as you well know recently found i believe 311 million for fy2014 in improper payments for the nonv. A. Medical care program. Id like to know whether the what progress has been made in the audit program, the Recovery Audit Program. My understanding is there is a request for proposal or that that that program is in the works. Could you update me . This Recovery Audit Program i am not immediately familiar with. Im familiar with the efforts we ear doing to expedite and improve the processes around prompt payment i know some of the payments that were identified as improper payments had to do with the fact that they were done under individual authorization instead of under provider agreements which is one of the reasons were anxious to have provider agreement authority. Well get you some information on the recovery effort and because im not converse zant on that at all. I would appreciate your giving me whatever information you can and hopefully in the next very future. Well do that, yes, sir. Thank you. Senator tillis . At this time i wont do a speech. Its gone from 50,000 feet to the ground level. Doctor, you mentioned when we were talking about for doctors who may go into the Choice Program that if they are already certified to provide medicare or medicaid coverage that you provide that doctor a provider agreement to allow them to provide v. A. Care. What is that provider agreement like . So so the way it works right now is we have contractors, health med and triwest, they contract or work with the providers. The provider agreement is two pages, very simple process so if a veterans want to like i was describing see someone in fayetteville, north carolina, and theyre not part of the network, its the responsibility of our contractor to reach out to the provider, give them the agreeme agreement, have them sign it and join the network. But its not a twopage agreement with 57 attachments . Its a twopage agreement . Its a simple agreement that has issues that relate to credentialing,est, ability to share medical information. Do you have any idea what the rejection rates acceptance or rejection rates on provider agreements . I dont know. Very low . Okay. Do you have any information on how well were doing with reimbursements for people who come under that versus a medicare or medicaid provider in terms of timeline to reimbursement, those sorts of things . In the Choice Program through our contractors they are close to 100 payment within 30 days. In the direct payment from v. A. , not through our tpas, we are at 79 payment within 30 days working on an upward trend to get that much better. Okay and then the real question is, is the 79 relatively simple care versus more complex care so that you get an idea of the dollars outstanding not just the no, our care in the community can be very complex care as well and thats what i was referring to. So is there any potential 80 20 rule where 80 of the 21 outstanding more than 30 days is 80 of all the dollars outstanding . The common metric thats used is they differentiate claims into whats called clean claims, claims that have all the information there, and claims that are not clean claims so they dont distinguish them by clinical criteria, whether theyre more complex or not. So if i go out and talk to providers getting into choice theyre no longer telling me its very, very difficult to do and theyre not getting paid on a timely basis . Providers sometimes dont differentiate choice from v. A. So youll hear both things. Thesht be getting their payments 100 of the time within 30 days through choice and thats because it could be a nonv. A. Provider by contract and a choice provider by episode . Right. Exactly. Okay. Thank you, mr. Chairman. Youre welcome. Gentlemen, thank you very much, secretary gibson and shulkin, doctor, thank you. Ill ask the next panel to join us at the table. We should be joined by mr. Rosco butler, director of the Veterans Affairs and rehabilitation of the American Legion. The senior Veterans Affairs advisor for concerned veterans of america, bill rauch, political director for veterans of america, mr. Kelly, director of veterans of foreign wars. And while youre taking your seats i want to apologize that i have another commitment. I didnt realize this hearing would last as long as it has and so i may have to depart before youre done with your testimony. If that happens, i apologize and ill leave the hearing in your hands, mr. Chairman. You have no alternative. Thank you, senator blumenthal. Gentleman and maam, thank you for joining us. Well begin i cant see the name tag but i think its mr. Butt lore. Please proceed. Thank you acting chairman moran, Ranking Member blumenthal and members of the committee. The American Legion believes in a system designed to treat the unique needs of those who have worn the uniform, however in the best of circumstances, there are situations where the system cannot meet the needs of the veterans and the veteran must seek care in the community. I am privileged to be here today and to speak on behalf of American Legion, our National Commander dale burnett, and more than two million members in over 14,000 posts across the country that make up the backbone of the nations largest wartime Veterans Service organization. The American Legion recognizes that the Choice Program was an emergency measure to make Health Care Accessible to veterans where v. A. Was struggling to deliver such care. In recognition of the needs of an integrated system toll deliver nonv. A. Health care when needed, the American Legion believes v. A. Needs to develop a welldefined and consistent nonv. A. Care Coordination Program with appropriate policies and procedures that include a patientcentered strategy which takes veterans unique medical injuries and illnesses as well as their travel and distance into consideration. The v. A. Purchase care Program Dates back to 1945 when general paul are harrelly, chief medical director of the veterans administration, implemented v. A. s hometown program. The general recognized that many hospital admissions of world war ii veterans could be avoided by treating them before they needed hospitalization, as a result, the general instituted a program for Hometown Medical and dental care at government expensions for veterans with serviceconne serviceconnected ailments. Under the hometown program, eligible veterans could be treated in their community by a doctor or dentist of their choice fast forward 70 years, v. A. Has implemented a number of programs to manage nonv. A. Community Health Care Programs at the request of congress, programs like fee basis, project arch, patientcentered Community Care and the veterans Choice Program were implemented to ensure eligible veterans could be referred outside the v. A. For health care if needed. V. A. States their Community Care program would streamline the above programs by transitioning them into a Single Community Health Care Program that is seamless and transparent to veterans. While these goals sound positive, the American Legion believes by resolution to a proper plan for nonv. A. Care must include the following elements. Ensure all nonv. A. Community Care Contract provides complete military cultural awareness and evidencebased training. Provide all nonv. A. Providers with full access to v. A. s computerized patient records system. Ensure v. A. Continues to improve its nonv. A. Coordination through the nonv. A. Care Coordination Program office. Ensure v. A. Improves collection of nonv. A. Documentation into the veterans medical record. Ensure v. A. Develops a National Tracking system to avoid national or local purchase contracts from lapsing and an automated claims Processing System that fully out lates the authorization and payment process. Were pleased to see that v. A. s plan incorporates many elements of our resolution if approved by congress the plan would be rolled out using a threephase approach. The plan would be implemented gradually, much like tricare, by developing appropriate Provider Network streamlining business processes. Additionally, v. A. Plans call for cultivating a Provider Network to serve veterans utilizing federal Health Care Providers, academic affiliates and Community Providers. The American Legion believes v. A. Has not yet demonstrated it has the expertise or experience to establish large Provider Networks. So far this year it has relied on thursdayparty participants such as health net and triwest to fulfill these requirements. V. A. Does not specify whether it will continue utilizing thirtyparty contractors to fulfill this requirement if the plan is approved. Serious thoughts need to be give on the this question. V. A. Plan is clearly a huge undertaking and we have concerns about v. A. s ability to implement the plan. V. A. Has attempted to roll out or has rolled out numerous projects in past years that required dramatic system Information Technology and policy changes. V. A. Must guarantee congress, vsos and veterans that their Community Care plan is l not result in similar failures like other projects such as core fls, scheduling redesign, a veterans lifetime Electronic Health record, v. A. Four Major Construction projects or the initial rollout of the Choice Program to name just a few. Veterans are calling on v. A. To get it right and on their first attempt and not continually waste taxpayers dollars. In summary, if v. A. Can address the American Legions concerns, we are cautiously optimistic that v. A. Plans for moving forward could represent an important step toward a truly integrated model for delivering Veterans Health care within v. A. And the community collectively and, again, i thank the committee for their hard work and consideration for this legislation as well as your dedication to finding solutions for problems that stand in the way of delivery of Veterans Health care and im happy to answer any questions. Thank you very much. Thank you, chairman moran, Ranking Member and members of the committee. Appreciate the opportunity to testify at todays hearing on the recently released v. A. Plan for consolidating nonv. A. Care programs. In the interest of full disclosure i am a commissioner on the commission of care. My testimony today reflect misown personal observations and does not reflect nor is it representative of the commission, the v. A. Or the zrags. Are cva agrees there needs to be one new program that deals with the problems in a fiscally responsible way with the veteran in control of how, when and where they wish to be served. This has been a stated goal of the v. A. Although we laud the v. A. In coming up with a plan for the program, after careful review its our opinion this plan does not meet the criteria listed above. It continues the v. A. s status quo, cherry picks the assessment and ignores the commission on care. The plan will fail, costing taxpayers billions and impact nell tivoli on Veterans Health care. Instead of a simple program, v. A. Has developed a grandiose plan that doesnt deal with the challenge it faces nor does it provide services found the industry. It is expanding into areas it does not have expertise in. We identified five key flaws in the plan. First implementation required a highperforming Health Care Organization such as the cleveland clinic. Vha is a loweperforming Health Care System based on socialized medicine using an antiquated hmo staff model focusing on a high degree of control. As the independent assessment stated, solving these problems when taken together amounts to a system wide reworking of vha. The number of problems they face appears overwhelming, vha is in the midst of a crisis and they here in danger of becoming obsolete. Last year vha made 85 million appointments but only completed 55 million appointments. Recent headlines such as lapses in urology care in phoenix v. A. And reports suggest vha is not up to the task. Second v. A. Has provided a concept plan that proposes lofty goals and is not grounded in the reality of the way veterans access their care vha is operating under the false premise that it is the home for the veterans it serves while providing a minority of their health care. Reliance ranges 15 to 34 from office based visits to laboratory services. Third, v. A. Gives lip service to the independent assessment recommendations findings and Systems Approach but cherry picks recommendations and ignores others. Its focused on whats best for it instead of embracing the tool, operations and leadership reforms needed. Fourth, veterans want real choice in private health care according to an october 2015 poll, 91 of veterans want more health care choices. Instead, v. A. Takes greater control over veterans eligibility and access. Veterans would be eligible if they are more than 40 miles from a designated pcp. This is unrealistic because veterans pcps are not designated from v. A. And most of them need care from a specialist. V. A. Is gaming the system by having undefined wait time goals and leaving it up to the provider to decide the time frame. Accessing the High Performance network is another example. They have an undetermined referral process which could take months for each step. First hurd is the core network, then the prefered tier controlled by v. A. The plan is premature in light of the charge Congress Gave the commission on care to examine how best to organize vha and deliver health care to veterans. The v. A. Plan could short circuit this charge and be in conflict. To overcome the flaws and challenges, cva proposes the follow three steps. One, v. A. Should focus on the shortterm solutions of consolidation that is phase one of the plan which should be refined with implementation, evaluation and in consultation with if the commission on care. V. A. Should refine phases two and three of the program in consultation with the commission on care integrated system approach with proper governance, data and tools, operations and leadership reforms. Three, v. A. Should finalize phases two and three after the commission on care provides its findings and recommendations to the president and congress. They are attempting to move too quickly and we must break the cycle of reform and failure by having the right plan that focuses on the Veterans First, not the v. A. As president Theodore Roosevelt said, a man good enough to shed his blood for the country is good enough to be given a square deal afterwards. Lets make sure veterans get the square deal they deserve. Cva is committed to overcoming any and all obstacles and we look forward to working with the chairman, Ranking Member and all members of the committee to achieve the shared commitment to veterans. Thank you. Mr. Rausch . Acting chairman moran, Ranking Member blumenthal. On behalf of iraq and afghanistan veterans of america and our 425,000 members and supporters, thank you for the opportunity to share our views with you today at the hearing consolidating nonv. A. Care programs. I ava is proud to have testified before this committee recommending the need for consolidation and care for veterans enrolled in v. A. Health care and we applaud congress for requiring v. A. To put forward a plan. We also want to recognize Senior Leaders at v. A. Who are still with us here today for acknowledging the need for consolidation and providing an approach and process that was inclusi inclusive, transparent and veterancentric. Last year as if muchneeded veterans access to choice and accountability act was implemented it became apparent to our members across the country the new role was confusing and added to preexisting v. A. Programs decided to provide care in the community, according ing ting the reason they didnt utilize choice because they didnt know how. 28 of our member mos who utilized the program says their experience was negative although necessary to address the access crisis at v. A. Revealed by the scandal in phoenix, the Choice Program became an example of what was and what was not working for veterans, physicians and v. A. Employees when it came to providing accessible, timely and high quality care in the community. Aava has conducted polls, focus groups collecting feedback from thousands of our members while working with industry and other stakeholders to understand what was needed in order to have consolidation of care in the community. Weve attended over 25 formal meetings with other vsos and v. A. Staff to show what members were experiencing at the local level and have had dozens of additional informal calls to provide direct feedback from post9 11 veterans. Iava believes any plan must be simple to understand, it must be consistent across the country and place the needs of veterans above all else. The plan put forward by v. A. Meets the above criteria and should be the pram work for legislation in order to consolidate care and provide improved and seamless access to care for veterans. Despite the progress made by congress, v. A. And veterans across the community we have three main concerns. One, congress drafting and enacting the required legislation to effectively consolidate care, two, v. A. s ability to effectively implement the new laws designed to designate and consolidate care and three focus on access without enough emphasis on Health Care Outcomes for veterans which was talked about earlier. Especially as veterans see providers who have not historically served the veteran community. Congress acted swiftly and put Veterans First in the wake of the access crisis bypassing the choice act and this committee has been a Strong Partner with iava, unfortunately , some members of congress continued to put forward incomplete one off plans and legislation that didnt include feedback. As Congress Moves forward to simplify a very confuseing process for veterans by drafting legislation to consolidate care, iava highly recommends they use congresss plan for framework and avoid one off proposals that are misinformed or put politics ahead of veterans. After all, congress provided by the numerous different plans that added to the conclusion which resulted in the need to consolidate care. We believe congress should be mindful of these Lessons Learned from them and leverage the plan moving forward. Our second concern centers around v. A. s ability to effectively implement a plan to consolidate care in a way that avoids mistakes made during the implementation of choice and puts the veteran at the center of every decision. During a round table at my v. A. Medical center with post9 11 veterans one of our members stated there 150e7seems to be consistent inconsistencies across v. A. And although ive had positive experiences, too many have had bad experiences. In order to address these inconsistencies and shortcomings iava recommends v. A. Includes all stakeholders who share the vision of putting Veterans First and focus on valuesbased leadership. Given the serious shortcomings related to training front line personnel in Customer Service gener generally, the v. A. Should continue its efforts with my v. A. And must ensure all v. A. Employees are consistently trained on any new plan to consolidate care. Finally iava encourages everyone, congress, v. A. , vsos, industry and other stakeholders to place increased importance on the quality of care veterans receive. As specially as new providers join network to provide care in the community. We need to spay special attention to ensure the quality of care is consistent with the high quality of care provided by by v. A. And pro providers are educated on how best to treat our veterans. As providers are called upon to serve this population, a recent report suggest Community Providers might not be well equipped to address the need of veterans and specificallies specifically for posttraumatic stress and other injuries. In closing, iava would like to thank this committee for your leadership and commitment to our community of veterans. Its a privilege to testify in front of this committee today and we reaffirm our commitment to you and working with all of congress, v. A. And our vso partners to make sure veterans have access to the highest quality of care available and our country fulfills its sacred on ligation to care for those who have truly borne the battle. There have been real tragedies in the past. Weve talked about them today however we believe there is a real opportunity to transform the v. A. For todays veterans through a one team one fight approach. Thank you and i would be happy to field questions. Mr. Rausch, thank you. Now mr. Kelly. On behalf of the independent budget partners thank you for the opportunity to testify today. The partners strongly believe veterans have earned and deserve to receive high quality comprehensive accessible is veteran sent rick care. In most instance, v. A. Is the best option but v. A. Cannot provide all services to all veterans at all location at all times. That is why v. A. Must Leverage Private sector providers to expand viable options. After months of working closely with v. A. Officials and other stakeholders we please misdemeanors ago expects of the plan are closely aligned with veteran Health Care Reform framework. The iv partners support the concept of consolidating existing care in the Community Programs into a Single Program that would seamlessly combine cape abilities of the Health Care System with other public and private Health Care Providers in the community wherever necessary. Several Community Care programs would be allowed to sunset while allowing these programs to sunset is a natural progression in the development of the consolidated Community Care program, allowing them to expire without assurances the new plan has the capability to handing the workload is unacceptable. The partners also support the idea of expanded access to emergency treatment and provide access to urgent care but we can not support an acrosstheboard copayment. The idea of charging veterans who are Service Connected for care is unacceptable. In an effort to ensure veterans utilize urgent care appropriately we suggest the establishment of a nurse advice line. While the ib partners agree v. A. Must do a better job of collecting Third Party Payment wes oppose withholding health care from veterans if they fail to provide other information. Rather than punish veterans for not providing private insurance v. A. Should consider ways to incentivize veterans to pro pride that information. The framework builds on v. A. s progress by addressing barriers to progress by addressing barriers from outside v. A. s plans limited to scope, which ill discuss now. Our fourpronged approach framework looks beyond the Current Organization and division between v. A. Care and Community Care to create a blended and seamless system that will restructure the Veterans Health care delivery system, redesign the system, and the systems that facilitate access to health care, realign resources to reflect its mission, and reform v. A. s culture with work force initiatives and accountability. Similar to v. A. s plan, the framework would combine the strengths and capabilities of v. A. And other public providers. Included would provide rural and remote veterans with options to receive veterancentric and coordinated care, regardless of where they live. We recommend the v. A. Move away from a single arbitrary federally regulated access standard under the i. B. s framework, access to care would be clinically based decision made between veterans and his or her doctor or health care professional. Once the clinical parameters are determined, veterans would be able to choose among options developed within that work to schedule appointments that are most convenient to them. The i. B. Calls for significant changes to v. A. s Strategic Capital investment plan, or skip process, but including Public Private Partnership Options and blending existing replacement options to better leverage federal and local resources. Help provide continuity of planning across all administrations. The i. B. Framework would establish a bienial independent audit, to identify accounts and programs that are susceptible to waste, fraud, and abuse. In addition, we call for strengthening v. A. s veteran experience office by combining its capabilities with the patient advocate program. Veterans experience officers would advocate for the needs of individual veterans to encounter problems obtaining v. A. Benefits and services. They would also be responsible for the health care protected under title 38 are enforced. Our plan uses public and private resources as proposals that provide veterans with vouchers or insurance plans. Its complementary instead of in competition with each other, which will be key to providing quality care. This concludes my testimony. And me and my partners look forward to any questions you may have. Senator blumenthal. Thank you. I appreciate your courtesy in allowing me to ask a couple of brief questions first. Let me ask you, your recommendation is that the v. A. Should finalize its Choice Program, the longterm new veterans Choice Program, only after the commission on care provides its findings and recommendations to the president and congress and theyve decided which recommendations are feasible and advisable. Do you have a timeframe as to when those recommendations will be made . As of right now, based on the legislation, we are due at the end of february. In february. As of right now, thats when were due. And so you would advise waiting until sometime this spring or later when there is feedback from the president and congress before the v. A. Finalizes its Choice Program . Yes, i think the v. A. s plan has some merits to it, but it has a lot of work that needs to be flushed out. Its a concept plan. And that can be done. Once again, im speaking for myself, not for the commission or anything. But personally, i feel that, you know, it can be a more collaborative process. And as part of that collaborative process, lets have a process where we have a really integrated Systems Approach where we come up with an overall comprehensive solution that the Choice Program is not a solution on its own. It has to be integrated with the rest of the Health Care System. And so coming up with a program on your own, that may be in conflict with other recommendations. Would just cause more confusion. Mr. Ralph . Require wou. I would just like to add, although we have different views and opinions about this specific plan, i would challenge anyone to suggest that the process hasnt been collaborative. And in contrast, to say two years ago working with the v. A. , i dont believe that this process would have taken place, and based off of a lot of discussion between members of this committee and senior v. A. Officials, just moment ago, it seems that your experiences have also changed with the v. A. , and so i would just like to highlight, as i did in my testimony, the numerous i mean, it was almost daunting. Frankly. So i would just emphasize that its been transparent, its been collaborative and unprecedented from our perspective. Thank you. In full disclosure, i think it would be fair to say that the commission you met with their professional staff. Its our understanding that theyre hoping to extend their charge at least until next summer, which would mean this discussion would presumably put off until june, july, or august of next summer at the earliest. I think that would be an unfortunate occurrence for the v. A. , because as most of us here have testified, this plan that the v. A. Put forward is a good idea. Its a very good concept for how health care should be delivered. If we just put it off for another potentially 12 months, where will we be now, and will that really solve the problem that were trying to address . I share the concern about timing. I understand mr. Selnicks point about collaboration, but im heartened and encouraged by the feeling that i think is generally shared among this panel, that the process has been collaborative. And to that end, i am going to invite, in fact request, that the v. A. React to some of the excellent ideas that have been suggested by this panel if they havent done so. I would ask that the v. A. , who are still present, let the record show that all of the witnesses on the prior panel are still here. And can hear me make this request. I would ask that they react to these proposals because these ideas are very promising and important, and i think collaboration is the keyword here. The vsos have been extraordinarily and profoundly important in this process, and i want to thank all of you, gentlemen and lady for the excellent ideas that youve offered today, and throughout this process. Those who were represented here and others who were not on this panel. So thank you very much, and ill look forward to additional collaboration. I think thats the operative word. Thank you. Senator moran . Mr. Chairman, thank you very much. I think it was mr. Roush who had statistics about experiences with the Choice Program, access to care. Let me ask all of you, youre all involved in helping your members helping veterans access care. Whats been the experience with the choice act for each of you, each of your organizations members . For the American Legion, weve had experiences where veterans have had positive experiences as well as not so positive experiences. It all depends upon the type of relationship the v. A. Has within the community, and with the health net. Were still getting calls where even from veterans where their claims have been turned over to collections. Because theyre not being processed and paid in a timely manner. When we get those issues and concerns, and we turn them over to our vso liaison and central office, and after they check into that, then we get an affirmative answer as to what was the breakdown, and an easy solution to fix it. But then the question then becomes how come we why did we get to that point . How come it wasnt appropriately addressed in the beginning . For our members, its been mostly a nightmare. The number one thing that they say, literally the few that have been able to get choices because theyve had congressman or senators interfere on their behalf. The common thing is why does it take a congressman or a senator to get some help . The whole process, our members, and you can go online and see the facebook posts. Just been a continuing struggle and battle. And one of the number one questions that we get is look, if im within 20 miles of the v. A. Hospital with the heart surgeon i need, why am i denied that choice . Why cant i get the Service Within 40 miles . Why does tricare offer a simple system of specialty and primary care metrics and the v. A. Has this convoluted process . Thank you, senator. Just to repeat those numbers currently, 43 of our respondents state the main reason for not using it was confusion, and 28 said they had a negative experience. Weve seen from our polling data, a lot of flash polls, social media, weve seen it increase, albeit generally its still been a negative experience. But its increased exponentially. And you mention kansas, and i spent some time at ft. Levin worth because i was assigned there, by choice. So i knew kansas fairly well, and i was looking at a map recently that the triwest had showed me today, or last month, excuse me, versus a year ago, the providers and the network that they built in kansas specifically has been tremendous, and so what weve seen is not a linear increase, but an exponentially increase in the number of providers, veterans who understand it better, the v. A. , who frankly were probably the worst understanding how to coordinate the care. Theyve improved significantly. And so although its been a challenge, we have seen it start to sort of steadily uptick, which is why we mentioned also in our testimony that theres some really positive things and Lessons Learned from choice, but also some negative things weve learned. And just on the broader, you know, concept of choice, it was mentioned earlier about the different plans that have been floated, and again, one of the reasons we support this framework and reject some of the oneoff plans, you know, there are certain plans that want to take, as someone mentioned earlier, primary care out of the v. A. Well, as someone who actually had my primary care Health Appointment this morning at the v. A. , and i had choice, because i have private health care as well, that would be removing choice for me. So there are certain plans out there that actually dont reduce, but completely eliminate choice by poulling some of the resources out of v. A. , which is why we think the collaborative approach that has been taken is a great and clear path forward. Thank you very much. And i appreciate your patience in waiting for the opportunity to testify and to be here to ask questions, which gives me the opportunity to tell the v. A. How appreciative i am of their patience and staying to listen to the testimony. And i apologize for having to go to the floor and make a brief speech, so i missed almost all of your testimony, which i apologize for, but ive been reading through read through last nights testimony. I have a couple of quick questions. I know its been a long time, but i thank you for staying. I thank the v. A. Rempresentativs for staying and listening as well. Mr. Selnick, you heard exchange with senator moran and myself about the v. A. And the problems in kansas and the choice accessibility and the ease or difficulty of that program . You made a comment a moment ago that you werent sure that those providing services at the local level and the v. A. At the washington level understood how the program was really working, or Something Like that. Did i hear you right . Well, i mentioned a number of different challenges with the program, its staff, its process, its call center, the whole thing has been a problem. And i think youre right. And i dont blame anybody for this. But i think there is a misunderstanding up and down the chain of command in terms of what the intent of choice was and what some of the changes we made. I hope as we implement these two changes yall rolled up yesterday, youll make sure that people at the local level and the hospitals and medical facilities understand what that really means in terms of the veterans access, because those are two remarkable changes that will make choice better for every single veteran tomorrow, but if they dont experience it at the local, its not going to be any good to them at all. Mr. Butler, i want to read a ive got two questions for you. One, i want to read this. The v. A. Needs to provide all nonv. A. Providing with full access to the computerized patient record system to ensure that the Community Health care providers can review the patients full medical history and continuity of care purposes. Earlier in your testimony, you referred to the lack of coordination between the nonv. A. Providers and the v. A. In terms of getting the documentation of Services Provided so that Veterans Health care file is complete. Is that right . Correct. Do you think theyre capable and i agree with you. No system is going to work if you dont have the medical history of the patient and the services they received in one place, easily accessible. Do you think theyre capable of doing that . Well, the v. A. Has been working on an Electronic Health record for years now with very little success. Their plan calls for taking the snapshot, the process, i believe. Which is a virtual snapshot of the veterans record and incorporating that initially as part of the health record, and then moving on with a future design of a more coordinated health record. I think for any process to work, youre beginning to have allow a virtual Electronic Health record, which the whole industry is struggling with. But youll have to develop a virtual Electronic Health record that is transportable and shareable between any health care institution. Until we get to that point, youre going to still see the challenges of sharing Electronic Health information, either way, between the v. A. Versus nonv. A. Providers and vice versa, between the nonv. A. Provider and v. A. You just hit the nail on the head, because the biggest problem forget about the v. A. Health care for a minute. The biggest problem is the lack of interoperability between data systems. Youve got greenway, youve got serner, youve got epic, youve got these systems that dont take to each other, so its great to talk about having the information, but if you cant get them interoperative and talking to each other, you cant have an ease of a file. If you want to jump in here and say something. But if were going to make this thing work, if its going to be the way you suggested youd be subjective of it working, the first hurdle well have to overcome is how do we make the systems interoperable between the nonv. A. Providers we use and the v. A. System to get the information on the veteran in one place, one time, accessible by the physician and the veteran as well . Right, sloan . Our new technology lady, has she figured out how to do that too . Some of whats being described is actually available. I think that observation that you made, roscoe, in your testimony is key, that maybe this will function into doing well. I appreciate you bringing that point up. Appreciate all of you being here to testify today. Appreciate everybody who stayed for the duration of the hearing. I think it was very effective. We look forward to working with the v. A. And all the vested parties to see to it that as we roll this out, it work for the person thats here to serve, and thats the veterans of the United States military. With that said, we stand adjourned. As 2015 wraps up, cspan presents Congress Year in review. A look back at all the newsmaking issues, debates, and hearings that took center stage on capitol hill this year. Join us thursday at 8 00 p. M. Eastern as we revisit Mitch Mcconnell taking his position as Senate Majority leader. Pope franciss historic address to a joint session of congress. The resignation of House Speaker john boehner, and the election of paul ryan. The debate over the nuclear deal with iran. And reaction from congress on Mass Shootings here and abroad. Gun control, terrorism, and the rise of isis. Congress year in review on cspan, thursday at 8 00 p. M. Eastern. Congress begins the second session of the 114th congress in january. The house is back for legislative work on tuesday, january 5th. Among the items on the agenda, a budget reconciliation bill that would defund planned parenthood and repeal the Affordable Care act. The president says he would veto it. The Senate Returns the following week, monday, january 11th. Senators will consider a u. S. Circuit Court Nomination in pennsylvania, and a bill from kentucky senator rand paul that would require an audit of the federal reserve. The house is live on cspan. The senate live on cspan2. Tonight on cspan, celebrity activism. Well hear from elton john, ben affleck, duck dynastys Phil Robertson and others talking about foreign aid, poverty, and gay rights. There was a time when i thought it would be impossible to be out. And 18 months ago, with the help of your love and support, i shared my story. And everything changed for me. And im still feeling the effects of that moment today. And i know how lucky i am to be in this position. I acutely remember the pain i was in before i was out. And i have been able to experience a lot of things for the first time in the last year and a half. [ applause ] having my arms wrapped around my girlfriend samantha while we walk down the street. [ cheers and applause ] holding her hand on the red carpet. Kissing her in the ocean while we surf. Yes, she has taught me to surf. And getting to say in public, i am in love. When an atheist writes a check and puts the date down, hes saying jesus was here. Including you atheists in the crowd. You know what he did . Hes the one whom the cosmos was created, jesus. Died on the cross to take all your sins. Three days later, raised from the dead. That solves your grave problem. So the blood takes care of your sin, and the resurrection takes care of your fear of dying. You say, theres a way off planet earth alive. You got a better story . Lay it on me all of these isms, atheism, agnosticism, materialism, ideali idealism, naturalism. What is all that about . Trying to get around what i just told you. You can watch all the speeches from Phil Robertson and ellen page tonight on our companion network cspan starting at 8 00 p. M. Eastern. Next on cspan3, a conversation about terrorist attack, the syrian refugee crisis and whether Law Enforcement should be able to access encrypted data. Well hear from michael hayden, former Deputy Attorney general jamie gorlic. From the council on foreign relations, this is an hour. Thank you very much. Hi there. Thank you for coming today. We have a full house here in new york. I hope you have a full house there in d. C. My name is gina temple, and i am the counterterrorism correspondent for National Public radio, so ive been busy. As have todays panelists watching whats been going on in paris and brussels and San Bernardino. So what id like to do is briefly introduce the panel. And well talk for a little while. At 1 00, we will no, sorry. At 1 30, well go for questions from the audience. We can get that ready. So, here sitting with me in new york is robert vauder, senior principal at sentinel strategy and policy consulting. Hes a former commissioner of the u. S. Customs, so well have lots of questions for him about visas and waivers and things like that. In d. C. , we have jamie garelis, a partner at wilmerhale. Theres a wave. The former Deputy Attorney general with the u. S. Department of justice. And finally, almost a fixture here at the council on foreign relations, we have general michael hayden, a principal at the churchoff group and the former director of the cia and the National Security agency, and well have some questions about encryption and other things like that for him. Okay. So lets start. And well start here in new york. Because were live. Lets talk about the difference between large scale attacks and the more recent attacks weve seen in paris, and in particular San Bernardino. What kind of countermeasures can ameliorate Something Like San Bernardino . Well, let me start off by just saying that weve had two different kinds of attacks that have taken place in the recent past. The one that actually spurred this program was the large scale terrorist attack in paris. And so i think one of the assessments that i think that we probably had already made, should make, is that isis is engaging in asymmetrical warfare that it views as its enemy, so its not content to just stay within its territory in syria and iraq and protect and expand that territory and other territories within the middle east. Its not content just to use the internet to help radicalize singleton, lone wolf kinds of terrorists in place in countries like the u. S. , but that it is carrying out large scale terrorist attacks by individuals who have been trained, not only radicalized, but trained in warfare and terrorist tactics in syria and in iraq. But the large scale terrorist attack is the one i would submit that we need to be most concerned about. San bernardino i think maybe is an example of appears to be, by the way, very recent interesting article in the New York Times based upon the arrest of an aider and abetter to the couple that carried out the San Bernardino enrique marquez, the friend of syed farook. Yes. In any event, there it appears we werent sure, but it now appears clearer that that was an inspired terrorist attack. And by the way, inspired at least in part by the sermons and lectures coming out over the internet that radicalized farook and were still not quite clear how ms. Malik, her journey to become a jihadist terrorist. But it is more of the not large scale terrorist attack that is still managed by the way, they managed to kill, which is a terrible tragedy, 14 people. But a large scale terrorist attack, the type of paris terrorist attack where you had 130 people that were slaughtered. Mumbai, madrid, by the way, 191 people. Multiple simultaneous wellplanned terrorist attacks. Execu executed, be, generally by a half a dozen or more foreigntrained terrorists. That presents the kind of terrorist attack that i would say is most consequential, and therefore we want to make sure we prioritize and focus our efforts as a government and with other governments on preventing that. Obviously, we need to try to also prevent the San Bernardinos, the chattanoogas, the garland, texas, and so forth. But ive got to tell you, by the way, at the end of the day, no matter how good the fbi is, and they are good, if youre talking about singleton, lone wolf, radicalized terrorists being able to kill a number of people, thats beginning to happen, and its extraordinarily difficult to prevent. I applaud the efforts of the bureau to date in thwarting as many attacks as it has. General hayden, let me ask you a quick question which has to do with whether you see this distinction between cells and lone wolf attacks, cells being paris, lone wolf being Something Like San Bernardino. Are there ways to stop lone wolf attacks, if, for example, conversations about an attack are actually taking place over dinner in an apartment like it was in San Bernardino . Sure. You can reduce the likelihood. You can reduce the likelihood that even if attempted, even if successful, the number of fatalities is reduced. I agree totally. This is below a threshold at which you can have any realistic expectations that your Law Enforcement or Security Services can get this to zero. These kinds of things will continue to happen. I think theyre accelerated by what we see in the middle east. Youve got the inspiration coming out of isis thats acting like the hand of god carrying out the will of god. And a narrative that is genuinely underpinned by the battlefield successes. So as were talking in our discussion a few minutes ago, in addition to whatever tightening we might be comfortable with, and theres tightening we will not be comfortable with and should not do. Whatever tightening we might be comfortable with here, i use the phrase, between the 18 yard line and the goal, we need to kick the ball up field. We need to get the ball up in the offensive zone. Rather than restructuring our society because of this danger, lets do a little reconstruction out there, and this is a case where the physical destruction of the kinetic fight actually has a powerful ideological impact. Very often in my life experience, kinetic success carries with it ideological burdens. It might actually make the long deep fight a little harder to do. In this case, i actually see convergence. Imposing battlefield defeats on these folks undercuts their theological underpinning. And therefore you get a victory, not just tactically, but strategically. One additional comment. I totally agree with the analysis that what happened in San Bernardino was kind of what we were expecting from isis. Kind of the Charlie Hebdo level. Maybe Charlie Hebdo plot. Paris was a little surprising. Or at least surprising to me. It showed a growth in isiss ambition and sophistication and reach that was coming down at us frankly at a rate faster than i had anticipated. It was a bit more al qaedalike in that it was centrally directed and complex with multiple parts. Albeit al qaedalike, compared to what al qaeda has done and would like to do. So in one sense, we now have to deal with both ends. The increasingly sophisticated complex attack. Frankly, were better at stopping. And the spontaneous attacks, which actually might just be the cost of doing business. I agree with general hayden on one point. The one i really underscore is that this isnt just about defense. Its not just about defending against these attacks. The best defense here is a good offense. And the offensive strategy against isis, of course, is a subject for a whole other program. So were going to be focusing on the fact that when youre on offense, you still have to prevent these asymmetrical attacks by the enemy that wants to strike you in your homeland. Thats what we were able to do against the french in paris. Its what isis was able to do against the russians by taking down a commercial airliner over the sinai and the like. And thats the one we have to we have a good chance of preventing that. We are actually doing better than most people think, i think, in terms of our ability to prevent that kind of attack in the u. S. But there are undoubtedly room for improvement. Right. I should just stress that its far from clear that San Bernardino really had anything to do with isis beyond a posting on a Facebook Page just minutes after the attack started that said in broken english that Tashfeen Malik supported and pledged to abu bakr al baghdadi. So its absolutely fascinating. This is almost all the way up until the end something very typically al qaeda. Aqap, one of the shooters wanted to go and join al qaedas army in yemen. So i think everybody was very early to talk about this being an isis case, and i think we may find out its a tangential one. Id say isisinspired is what it appears to be at this point. Yeah, its very much tangential. Or maybe even al qaeda. Because apparently farook was radicalized going back to as early as 2007. So lets talk a little bit about the way you combat Something Like this. And jamie, i wanted to ask you this question. Theres been a lot of compare on the role of the state department, and whether or not they should be checking social media before they let somebody in the country. What are your views on that . Its not something ive studied. But i do think we are surprisingly for a country that invented social media not great at it. Were not great at surveying it. And were not great at doing it. And thats stunning to me that the enemy here is way better at certainly at using social media to foment and inspire. And we dont have to use mikes terminology, a counternarrative. We dont have the same power in that space that we should. And i think i dont mean to answer a question which was not the one you were asking me thats okay. But the two go hand in hand. I think you have to have a greater sophistication in government, helped by our pretty sophisticated private sector, to figure out what is happening out there and utilizing that. As robert said, when you havesy were in, and we said this in the 9 11 commission report, your very best tool is intelligence. And so youve got to use it where you can. You have to put proper boundaries on it, but you have to use it. So a couple of years ago, i was on the fellowship, that i was looking at the idea of big data and intelligence. This is a little before the snowden revelations. So this next question is both for jamie and for general hayden. Do you see big how do you see Big Data Analytics being used in this space . If you have all these people on social media, if you have to troll such a large amount of information, how can that be used in the space to try to prevent these kinds of attacks . Sure. Look, in this context, the concept of big data and how you why you want to use it, i think it just follows the path of what we would call disambiguation. You want to go into a very specific actionable things. And weve actually gotten fairly good at that. In terms of disambiguating identities so we can target someone for action or collection. So he or she doesnt get on an airplane. And so we do that. And we need to perfect that and use it better and expand it as part of the big data sea, would be social media information. An awful lot of what passes for analysis in the American Intelligence Community is targeting. It is disambiguation. Its going from the mass to the specific. Its him. That might be at the cost of broader strategic appreciation for whats going on. I said in aspen last summer, and ill paraphrase it, did you guys miss isis or what . Got a policy problem or an intel problem . Its probably a mix. But i often view that we may have been so busy as an Intelligence Community chopping down trees over here with great care, we werent chopping down the wrong chairs that we kind of missed the second growth forest coming up over here. So big data is good. Weve got to do that, perfect the disambiguation. But i have to tell you, instingively when i hear that, the other thought kicks in immediately. Dont forget you need to give your policymakers deep reach nuanced strategic appreciations so that youre not forever in a loop, where all youre doing is arresting or killing people. Let me add to that. Big data is being used by every American Company to really great end. We are capable of analyzing huge amounts of data, and citizens today generate huge amounts of data in a way that we didnt five years ago and certainly not ten years ago. So the ability to analyze to use machine learning, to keep ourselves smart about what is happening out there, whether it is the micro or the macro, is critical. And weve got to use it. Now, to be sure, when the government starts looking at lots of data, you know, alarming go off about what the protections are against the misuse of that data. I would rather focus on what the protection should be than say its too dangerous and we should be hands off. Because it is one of our key tools. And if we are blind to what is buried in the data, we are not going to be as effective in protecting our country. And as somebody who grew up in the Civil Liberties community, i would rather take the time to build a system that works appropriately than i would risk take the risk of not doing that, and having the American People be so afraid that they wholesale throw out Civil Liberties. Thats the real risk here. And we have to appreciate that when we talk about the massive pendulum swings that weve had in this country between security and privacy. Can i just add one real im not going to call this if i could, im not going to call this big data. I think one of the most important things that we did, and shortly after 9 11, was to essentially pause at the question of how could we use data more effectively that we had to better identify the small fragmented people that might pose a terrorist threat to the United States. It might attempt to enter the United States from abroad and pose a terrorist threat. And, of course, we will identify anybody on the terrorist watch list, not only when they enter jfk, but before they board an airplane. But the real problem that i thought a lot about, and what we did something about was the issue of how do you narrow down the haystack of those very really under 1 of people, and they are foreign nationals. Some of them now are foreign fighters that have trained in syria. How do you identify the potential ity, and the broadest Law Enforcement authority that any agency of our government has. Thats customs and Border Protection. How do you use that then to engage those small fragment of people in sophisticated counterterrorism questioning to determine whether or not they do pose a risk. And if they pose a risk, to deny them entry into the United States. Thats what weve been doing since shortly after 9 11. Thats using a lot of data, whether thats big data, its a lot of data through the automated targeting system, which is part of the National Targeting Center that was set up by customs and Border Protection. And so now not only can we identify the small fragment of people that might pose a threat, and then to ask them some questions before we allow them into the United States, because if youre a foreign national, you have no right to enter the u. S. But in that small group of people, and by the way, its hundreds per year, we deny entry, which means that they are put on an airplane and sent back. Now, the other thing were able to do now, and this has been since the underpants bomber as they called him in australia, since that time, were actually able to do this intervention before they get on an aircraft at a foreign airport like heathrow and so forth. And cvp actually has teams of officers there to do the counterterrorism questioning of the people that we determine are potential terrorists, so they dont even get onboard the aircraft. If we believe if we assess them to be a security risk, we simply tell the airlines dont board that person, and if theyre a visa waiver person, they have to go to the u. S. Consulate to get a visa and be subjected to an actual interview, a counterterrorism interview by the state Department Consular officials. So, one of the things that surprised me postparis was how there was such a debate about Syrian Refugees, and them coming not just into europe, but into this country as well. Two of the paris attackers as far as we know allegedly came through greece, possibly with fake syrian passports to come in. So let me start with general hayden quickly, and i think you had a comment about the last question as well that you didnt get to make. Do we need to worry about the Syrian Refugees . Ill get to that, and let me just do the other quick comment about what to do with big data and american industry discoveries and other things. I was on a panel a year or two ago with keith alexander, and eric schmidt from google. And we were talking about the nsa metta database, and eric was saying look, i understand why these guys want to do it. You run powerful algorithms, you public relationships, you learn this, you learn that, it goes on and on. And we were looking at one another and saying, well, if youre right, we dont do that. You know, the use of even that database was very narrowly circumscribed to quarry whether a known terrorist has ever had a phone call that ended in the United States. So youve got this unreal separation where the private industry takes it as a given that you would do it this way. Not so much. With regard to the refugees, sure, stupid along with being generous. So my short summary would be simply that i would advise the chief executive to speak like and act like mother teresa, and then before the meeting broke up, to grab whoever is stealing my chair now, pull him aside, poke his finger into his sternum and say you, you make sure nothing bad happens. We can do both. Weve got talent in this. Should we be worried about them . Isnt it harder to get in . There is a danger. We should be prudent about it. Just simply saying it aint gonna happen is actually destructive of our security. Not just destructive of our character. Another example of overreaction in our country, and which we see i think after every terrorist attack. And Congress Almost always overreacts. Its all axiomatic. But the fact of significance i dont think is that there were a couple of people with syrian passports that came into europe that way. The fact of significance was that there were foreign terrorist fighters who were belgian citizens, french citizens, citizens of other countries who had fought and been trained by isis and had european passports. And were able to come freely back anywhere in the eu. Thats the more scary data point than the refugees. Because the refugees were able to its a long process. We are capable of vetting. It takes acute questioning. It takes what general hayden said, a president who tells the department of Homeland Security secretary make sure somebody that faces a Security Threat doesnt get in. But that process takes time. There is vetting. Theres certainly the opportunity to make sure that thedc refugees that we do admio not pose a Security Threat to our country. But the visa Labor Program i think actually poses more of a threat. Because the estimates are 5,000 western europeans, french, belgians, uk that have gone off to syria and are fighting for isis. I mean, some of them are going to be killed and that sort of thing. Now we know isis is intent on sending some of these people back asymmetriasymmetrically. Thats the more fact of concern. I do think, by the way, i told you a little bit about the fact that we do have some protections in the visa waiver program. Congress just strengthened these protections by making it clear to the europeans that if they want to stay in the visa waiver program, theyre going to have to share information with the United States, with u. S. Authorities with respect to their own citizens who have gone off to fight with isis. Theyre going to have to have the capability of knowing who they are. Thats an intelligence issue. Im not too impressed with what our e. U. Callings are doing with respect to even having the data that we need to help protect not only them, but ultimately to help protect the United States. They werent sharing that information before . Theres some sharing on the intelligence levels, but the fact is, if youre a german citizen, youve been to turkey for six months, you come back into germany, they dont even know youve returned to germany. Theres a random checking occasionally of passports in the International Airport of frankfurt for their own citizens. Or you could fly into france. You could be a german who was radicalized and trained there. Im just saying theyre so far behind in terms of actually having a system to protect their own borders. Its not just shanghai. I mean their external borders protected by the weakest nations of the eu, greece and bulgaria. Secondlargest, by the way, the first is san yasidro. Their external controls are almost nonexistent. The socalled frame behind the paris attacks was on a watch list, one of the most wanted men in europe. He came back and forth several times between greece and was traveling between brussels and france and germany. So thats an example. Lets talk about encryption, because Everyone Wants to be talking about endtoend encrypti encryption, not just in the San Bernardino case, but also in the paris case. Jamie, should phone companies be required to respond to the process . I think every citizen, and that includes corporations, should be required to respond to process. Im speaking personally. My law firm represents Many Technology companies and i understand theres another point of view. But we have legislated that in kyliyah, which is a statute passed when i was Deputy Attorney general, and it implemented then, which basically said to phone companies you have to create the technical wherewithal, so that if a court on a finding of probable cause says we need this information, that that can be executable. And right now what our Technology Companies are saying is that is commercially very problematic for us, and therefore we are going to offer encryption across the board. And its true that there are also any number of apps. I mean, this is a this is a hard trajectory against which Law Enforcement is working. And my view is not beginning to be perfect. But we should enable the people who are there to protect us to get information where there is a laurel reason for getting it. And everyone else should be free to keep their secrets. But the bad guy should be able to have their communications discovered in a lawful process. Someone with a slightly different view may be sitting next to you. Youre being ironic, right . Yes. You cant see him, but hes vibrating. I cant see him squirming, but i can feel it from here. General hayden, let me sharpen that question a little bit and ask you, so the fbi director james comey said he thought that it wasnt a technological problem on the endtoend encryption, its possible to have a way that you could search that. But in fact, its a business decision that Silicon Valley companies depict on them. Can you talk about that a little sure. I think at the end of the discussion, its both. Its a combination of technology and business. And the fact of the matter is creating a door for the government to enter at the technological level creates a very bad business decision on the parts of these companies, because that is by definition weaker encryption than would otherwise be available. So you really dont have to split that baby. Both of those realities are true. If i was jim comey, i would have his point of view, all right . But im not and i never was and i dont expect to be. This is more a Law Enforcement issue than an intelligence issue. Because frankly, intelligence gets to break all other sorts of rules and to cheat and to use alternative paths. So im saying to say im speaking absolute terms, but i get jim comeys point of view. Yeah. You get to break rules not in the United States. Hes responsible for us. I get it. Im trying to be sympathetic, but it doesnt change my basic argument. Which are the following. I dont think its a winning hand to attempt to legislate against technological progress. I think the fact that you choose to criminalize it here in the United States does not stop it from happening. So thats one reality. I just dont think its worth the candle. Even in the security line, i think i can still win the argument. Its not as easy as that one. Its a much closer call. I get that. But even in the security line, i think americans safety and security and liberty is better secured with the highest level of technological capacity of secure communications, even though there is a cost to pay in terms of some specific Law Enforcement questions. Im joined in this by Mike Chertoff and mike mcconnell. Mike chertoffs phrase is we dont normally require citizens to organize their lives for the convenience of Law Enforcement. Mike mcconnells point of view, and mike lived the story, mike lived through clipper chip in the 9 0s where we were going to guarantee in the chip there would be a way in. And mike using the same arguments, mike fell on the sword and he lost. And mike would tell you now, and thus began the greatest 15 years of electronic surveillance in the history of the National Security agency. We figured out ways to get around it. Now, before any civil libertarians want to come up to me afterwards and get my autograph, let me tell you how we got around it. Bulk data and metadata. So there are tools that we can use at the intelligence level not easily available at the Law Enforcement level. If you are responsible for domestic safety, its a really hard argument to swallow that dont worry about it because we can find out stuff outside the United States. Thats number one. Number two, it is not true that we dont legislate to require people to organize themselves so that they can respond. We have all requirements on businesses that they have to be able to respond to certain inquiries that Law Enforcement makes. So my view of it is that. I want to clearly associate myself with the jamie girelli. Thank you. Perhaps thats my old Justice Department background. We faced a very similar issue. I was talking to jamie about it earlier. Technology does change, but the Cell Phone Company this is like only 15, maybe 20 years ago, max. Where billing out there switches. They didnt have any port authorized wiretaps to be able to intercept a phone call where there was probable cause to believe that a crime had been committed or was being committed, and that the user of this phone was committing it. And so this act, i mean, Congress Passed legislation that mandated that Cell Phone Companies basically build in portals for Law Enforcement use so they could access with appropriate court order and authority, so im telling you, look, if there is a potential terrorist in the United States, we have probable cause to believe that terrorist is in communication with another terrorist in yemen or someplace else in the United States and theyre conspireing to carry out terrorist attacks in the United States. I want to be able to get a tap on to that cell phone, or those cell phones that are being used, or the Electronic Communications that are being used to transmit those messages. And i think that with all due respect to general hayden, who i greatly admire, the fact that we dont have the capacity now because there are Internet Companies who want to sell privacy to everybody, even to criminals and terrorists, if not outrageous, its inappropriate. Well, i guess the argument also would be that if we require the United States companies to do it, there will be companies elsewhere that wouldnt. You mean other countries . Yes. Like china. I know the argument. But i think the chinese will do it anyway. The chinese are likely to do it the chinese are likely to do it, as are the french and the germans. So i dont think the mood in france right now is too hospitable for the notion that you can sell Encryption Technology that will prevent the french from exercising lawful process to get access to that information. Lets see. I just have to take personal pleasure in the thought that europeans are now in favor of really good surveillance. Me, too. I agree with that. There is something very satisfying about that. Okay. So ive eaten a little bit into the question time for our members and i apologize for that. Just a reminer, as you stand up to ask a question that this is on the record. Please wait for the microphone, and speak directly into it. And then state your name and your affiliation, and limit yourself to one question that is actually a question, and then jamie, you are in my role there in d. C. So give me a sign. Well alternate between questions. Okay. Let me start with this gentleman here in the front. Im standing. Ill state my name. Im a council member. I have one question. Shouldnt the head of nsa by law be a civilian confirmed by the senate as the fbi and cia directors are . Isnt this much too important role, with all due respect, much too important to leave to the generals . Ill leave that question to general hayden. Actually, theres some mistakes in the premise of the question. The director of nsa is indeed confirmed by the senate. The process is through the Armed Services committee as opposed to the intelligence committee. But it is a senate confirmation, as are all three stars. There is no requirement for the director of cia to be a civilian. In fact, i was director in uniform for i think 32 of the 36 months that i was director. The issue and finally, nsa, beyond its first initial being in, and i get that, is also a combat support agency of the department of defense. And that does drive in the direction of a uniformed officer. Youre right. There may be changes. Right now, most importantly, the director of nsa is also the commander of u. S. Cyber command. I dont think that can continue forever. All right . Its not too much power. Its too much work. And so a Cyber Command matures, then youll separate the two jobs. At which point you might want to give some thought, since you now have a Cyber Command out there with a uniformed fourstar. You might want to give some thought with breaking with tradition and using a career nsa civilian as director of nsa. So i think theres room to maneuver here. Take a question here in d. C. . Yes, please. The microphone over there. George mason university. The panel began by arguing that we need to get off the defense and go on to the offense. But this is not just a u. S. Isis or even a european isis problem. Its a very complicated regional problem. In some respects, whats happening in the u. S. And europe is the smallest element of it. So what does going on the offense mean . Mike, you want to start off . Sure. There is a powerful kinetic element to this. This is just on me with 39 years of military experience. I firmly believe that in this war the kinetic and ideological element are experienced in ways i have not commonly experienced in terms of breaking the narrative, hand of god, will of god, join the cause, and so on. So i think thats very important. Beyond that, though, let me go further down my politically incorrectly routine here today. I do think this is about islam. Its not about all of islam and certainly not about all of muslims, but theres a serious struggle within one of the worlds great judeochristian or european background, it has to be resolved within islam. I think Richard Haass rough approximation that this is islams equivalent of the 17th century and the 30 years war and all of that has a lot of elements of truth in it. I was heartened to listen to the emirates ambassador to the United States who talked about mode modern, moderate islam that is not about beating these guys down but creating a different vision for the islamic world. Thats something, again, we cant control or determine but to the degree we can support and influence, i think thats the winning hand. Nina, back to you. In the back there, with the blue shirt. There you go, that gentleman there. Greg chernny from cherny research. General hayden stated we needed to go on the offensive. Im wondering what that actually entails. We had 100,000 troops in iraq that was too many. That implies some kind of military commitment in between. In addition theres the old powell rule, the pottery barn rule, if you break it, you own it, and weve discovered theres a fair amount of reconstruction in the societies. Are we really prepared to make the kind of commitments that are required abroad to stem this tide . Yeah. Let me give a corollary of general powells rule, if it gets broken we appear to own it, all right . Seriously. I mean, three models. The involvement in iraq where we broke it. But we were really involved. And didnt end so happily. The involvement in libya where we try to split the difference. That didnt end very happily. And the involvement in syria where were barely present at all and thats not ending very happily either. Im not so sure the controlling element here in terms of things going bad is how much we or not involved in any point in the process. I do think that i am convinced that the right number for the american residual force in iraq was not a round number, all right . It was not zero. And not because those americans would sweep across and defeat isis, but because the political commitment those americans represented kept the court in some very powerful ethnosectarian bottles and once we were gone we allowed to set in motion things we did not create but have moved us in the direction we are now in. Theres no one in my experience other than Lindsay Graham calling for american maneuver units in the syrian desert. But 3,500 underresourced, overregulated and latetoneed American Forces is not the solution. There are many choices between the iraq occupation and what were doing now that i actually think have a reasonable chance of making the situation better, although it would have been easier to make the decision easier to make the situation better one years ago, two years ago, three years ago, or four years ago. The only bright side i can give you its easier to do it today than it will be a year from now. When we pulled out i dont want to engage in the beauty excuse me. I dont want to engage in the beauty of hindsight here and all of that, but i do think if were concerned about asymmetrical attacks in the United States and largescale terrorist attacks and on our allies, and i think we should be, then its very important that the u. S. Play a role in defeating isis in its own territory. And i think there are a lot of likeminded countries here including a good many sunni arab countries that share our interest. And france and uk and even russia. So, i think the real key here is, you know, how do we can this be done. By the way, i ask you, can it be done without u. S. Leadership . Ill leave that as a rhetorical question, but if it cant, then, i mean we have to be engaged and we have to have a broad strategy in which we were a lot of other countries lead the effort to essentially remove isis, because as general hayden is saying, i mean, its important to defeat them and to remove them because it also part of the their ability, quite frankly, i think to attract and finance themselves and that sort of thing is the fact that they are holding a sizable chunk of territory in syria and iraq. So, i think we do need to do something about it, but obviously its a question that is being debated and worthy of debate. Jamie, are there other questions . Yes, there are. People are literally jumping out of their seats. Hi, im christopher graves chairman of ogilvy public relations. We bemoan the fact that theres this insidious power of a conflunls of extremist narrative in social media and you said were failing at that side. Heres my question to you, we know in fluntion communication big myth that theres one message. When you look inside the great sec sprum that were caulking about in terms of creating a counternarrative, what have you learned so far from big data, from intelligence and from your experience works and doesnt work as an effective counternarrative . Well, a, i would answer that question this way, i am not the expert on what the counternarrative is and i am not convinced that we in the u. S. Government are taking advantage of the best minds in the United States to develop that counternarrative or to implement it. That was my point and my worry. I mean, we are operating as if we dont have the best minds in the country in the world on big data and on media, so really it was no more than that. I do think that the antimuslim rhetoric is a disaster for our National Security and we have to be able to figure out how to get our message conveyed in a way that underscores our values. I mean, when we wrote the 9 11 commission report, we talked a lot about the benefits of leading with our values. And we are just not doing that with all the tools in the toolbox. So, i dont have the answers. But i do know that we are not getting the input from the right places and we are, you know, mike says, you know, you know, you we shouldnt be dumb. Here were dumb. We are not being smart about using those tools, and thats all the only point i wanted to make. Nina, weve got a couple of other questions here. Can i go to a second one . Yeah, we have a couple we have actually quite a number here so you take the ones jumping out of their seats in new york. Go ahead. Well come back. Go ahead. How about this gentleman here in the blue tie . Hi. Its harvey rushakof with the american bar association. And hello, audrey, that was a great question. My question is given the experience on the panel, were going to have a new administration coming in in a few months. And what would be the organizational changes you would recommend to an incoming president that you think are a big priority given the threats were confronting and the organizational structure weve evolved and what would be the best that you would give to them in a few minutes . Id be curious im sure people would like to hear what you have to say. I thought i would start, jamie, since i actually was involved in the biggest reorganization of our government since postworld war ii which was the Homeland Security reorganization. I confess to be as atchison present at the creation but not necessarily responsible for every decision that was made. But i think there actually is a question in my mind whether or not we needed to restructure as massively as we did. But at this juncture having done it and not wanting to go through another reorganization, i would not suggest any massive or significant reorganization of the department of Homeland Security or its alignment with the Justice Department and other agencies. I mean, there are questions, for example, why wasnt the fbi the principal Counterterrorism Agency domestically, why isnt it in the department of Homeland Security . And there are some practical, interesting reasons for that, and im not going to go into them now. But, i mean, the fbi should be in dhs, but for a lot of reasons thats not going to happen. But there is one small i guess smallbore item i would say, and that is when customs and Border Protection was created which was the merger of all the Frontline Border agen agencies of the United States to form one Single Border Agency for our country and by the way, it does make us more effective and more efficient in terms of discharging the border function. But when that was done, at the same time all of the special agents, the investigators, if you will, of u. S. Customs, were taken out and removed from customs and Border Protection and they were put into an agency called i. C. E. And it was a little bit my analogy, and i see commissioner kelly out here in the audience. But my analogy is a little bit like taking the new york police department, separating off the detective units of the nypd and then expecting them to work welf together in terms and they do need to work well together. So, that isnt working very well, so i think we ought to relook at the issue of reintegrating the agents back into customs and Border Protection. Im sorry, jamie . Yeah. Either one. Let me just say two things. One is, i think that our instinct to reorganize the boxes every time something goes wrong is not a great one. I was there at the creation of the energy department. I watched the creation of Homeland Security. I understand why each of those occurred. You know, i think we need to examine that instinct because it does set back quite a bit the execution against mission when you do that. I think that the creation of the director o