senate down. those will force most provinces, almost all of them who have opposed senate elections and reform, to come clean with that and explain why the senators are not being elected. why the will not abolish. time, public pressure will force this issue to be resolved. frankly, the longer there are vacancies, it will raise questions about why we continue with the senate we do. >> one good way to come up for ideas is to meet with the trust issues? >> no, there is nowhere near agreement on reform or revelation and i think opening up the state department's decisions is a wrong priority. if the provinces believe the senate should be fixed, tell us how, they opposed that. >> thank you, mr. har harper. >> well paul, you could say there are broken promises and broken promises. mr. harper, promised he would never name an appointed senator. he has gone on to break a record naming 59. the list of conservative senators under investigation continues to grow. i am looking for a mandate on october 19th to put an end to this mess once and for all. canadians deserve better. making sure every vote counts, open up parliment, and making sure every dollar is spent in that committee. we do want to get rid of the senate. abolition pure and simple. mr. trudeau thinks me need better s bett bett better senators but i think we need previous senators. >> he broke the promise on his very first day as prime minister by appointing a senator to the senate. he broke that promise 58 more times. so i can understand why no body would believe him when he says he will not appoint any more senators. they want to open up the constitution, but the fact of the matter is when the next prime minister sits down with people, i can tell you canadians want to talk about jobs, climate change, health care, not talking about how to open up the constitution to try to improve the senate. the liberal party took concrete action to remove senators from our caucus to make sure any future appointments are done in a transparent, non-partisan way. >> with all due respect, whoever gave the advice what you are doing is constitutional, you need to go back to law cool. the single biggest scandal wasn't the misspending but the notion that the prime minter's office as the right to tell the conservative senators how to vote. for the first time in the history of the country, a bill passed in a democratically elected house. when it went to the senate, the senators were instructing to kill it. >> mr. harper, did you ask the senators to stop that bill? >> we ask senators to do, not force them, but we ask them to support the party's position and the party didn't support that particular bill. look at the facts of the parliament under the government. we hadilation -- of the situation. >> i was there with jack in front of the senate the day the senators were promeriting and the bills were adopted by those people da >> voted upon and enacted by the parliament. >> we asked the senators to stick to their principles. and the fact of the matter, this legislation has been blocked by the senate in the past. >> never. >> what is unprecedented is government legislation and i don't have to name senators. and we have 22 vacancy is we have a healthy government majority. >> you broke your promise 59 times. >> is there a record on that? for nearly three years we left some 20 vacancy in the senate and invited the provinces to fill them through elections, one one did. in 2008, i said i would appoint senators, we did so, and now we don't need to and we have stopped. but mr. trudeau, talking about truth. you said there are no liberal senators. there are 29 liberal senators working for the liberal party. >> mr. harper -- >> senate ovlution arequirementy required. is that not a problem? >> we would take a completely different approach to dealing with the problems of this issue of senate abolition demands a mandate. mr. harper has refused to attend a single meeting of the council of confederation. i go to two a year. i am not afraid of sitting down with my counterparts on things like health care we need a new and modern accord, of course i am going to sit down with them instead of dictating a big cut. on senate reform, i would ask for a mandate and start the hard work of meeting to get people on board to get rid of the unaccountable institution that is a relic from our colonial past. >> not only do you respect the government position against senate abolition it was your position all of the years you were in the senate in quebec. >> every success of government says it is a long standing policy. that is why i am not hesitant to sit down with my friend and colleagues and work on this tough issue. i believe sincerely the only way to deal with the senate is to get rid of it. $1 billion has been spent on the senate on mr. harper's watch. he did nothing about abolition, reform, can you imagine how many child care spaces we could have created with that much money? >> i would appreciate addressing this. the way the greens advocate changing the way we make decisions to work together is to create a council of governments including building on the council of confederation, representation from municipal and local governments, first nations and others around the same table. we need to deal with the senate. it is not my top priority because it is hard and it will require opening up the constitution. we think we should amend the amending formula so canadians can change the constitution by referendum instead of the way we we are saddled can today. >> mr. trudeau, are you associated with this? >> unlike mr. harper saying he directed the senators to vote along the party lines, i have not done that. we feel the decisions taken in the upper house should be independent of the political maneuvering. >> you broke the party line every single time. >> we have about 20 seconds. >> if you listen to mr. trudeau you would have to believe the liberal senators have changed. during the most recent election in nova scotian elections the bag man of the liberal party were up there thanking. >> larry campbell endorsed me and my group. >> i am afraid we have to say bye. stay with us for the final round and closing remarks. >> we have moved the viewing party left and taking a live look at the university of british columbia parked tonight as more youth tune into the issues impacting our nation. we approach the final leg of this debate. justin, i am going to start with you. what are you thinking on round two? >> i think mulcair was strong in the senate. he had a couple issues where he could have been stronger but got into the groove and went after the prime minister. elizabeth brought herself in the debut by knowing her facts and what she was going to say ahead of time. she got there, made her point, and i don't know if she will connect with the canadians but got into the debate. >> i agree with the point mulcair. i thought the prime minister came out scuffed up but not too beat up. >> what do you think about asking if he should apologize? >> that is a tough question. it was a little bit of an awkward answer. >> i think harper was good on the question of separation. with that came in and mulcair and trudeau were going after each other that was probably one of the stronger points. but he was on the hot seat taking a lot of attacks and we heard that is not true so many times throughout the debate and trudeau has performed well. >> harper taking a lot of heat. and canadians are piping up about issues on facebook. roger peterson with how you have been responding. >> kevin chan, we have been talking about the polls the latest one and look at the numbers. >> 82% of canadians watching tonight polling saying we should change the system >> not surprising when you think about how important government has been. >> people say government doesn't matter but when you look at the map it is the second highest discussion for the election. >> we will head over to gord martineau now. >> be sure to tune in after the debate and we will explore how canadians are responding in person and on online and here from the moderator about being in the middle of the action and that is where we are going right now. to four party leaders are in here toronto to talk on the final issue. >> welcome back. our final topic for tonight's debate is on foreign policy and security. if ever a choice between the choices canada makes at home it went away last friday when terrorist murdered forces in ottawa and st. john's. canada's security is being challenged in iraq and syria and our commitment to our allies are tested in eastern europe, our relation with the united states and world rising powers is another area of functioning. and we will discuss china and the world in the final section. >> tom mulcair gets the first question. canadians are not wanting to send soldiers into the combat but will defend canadian values by force when necessary. would an ndp government sent troops or jet fighters into combat? if so where? >> we have shown that willingness in the past with the case in libya. we agreed with the first two votes in the house and withdrew that when we changed the mission. canadian airlift went into ma malawi and we agreed. but i will think about the soldiers, their families, and make sure we have a clearly defining mission and exit strategy. that is why when mr. harper started the adventure in iraq he said this is not something canada should be involved in. every person on the panel agrees with the importance of fighting terrorism but the question is when do we put canadian troops in harm's way and we thought it was inappropriate. >> all of our allies support the mission against isis in iraq and syria. is that not a broad enough co e concensus? >> this is not a nato-led mission. this is an american-led approach. we know a lot of horrors we are seeing is a direct result of the last misguided war and i think frankly canada got it right when we said he would stay out of the 2003 war and we are seeing the results of that right now. >> first response going to elizabeth may. >> mr. mulcair, that second vote, with all due respect, with every member voted for the continued work in libya took place after the changes. the sanctions approval was responsible for protecting civilians. at the moment we as a country, canada, said the rebel forces, they are the legitimate government of libya we did that knowing the rebel forces included al-qaeda. i was the only member of parliament to who voted against continued fire because it seemed we should take the cease-fire and see if it worked. the warehouses were emptied out by hoodlums and terrorist and destabilized malawi and some of those very weapons handed up in the hands of isis. so the question is why did we as a country and never ndp member vote to continue bombarding them when everything was clear? >> i guess the answer to that and we will always evaluate it based on whether or not it is the united nation's mission when it came clear to changed into a situation of regime change we didn't vote. ms. may is opposed to every single possible use of our military. mr. harper is in favor of every single use of the military. we will take a balanced approach that takes into account traditional values. >> justin trudeau while doing this questioning, do you think we need a united nations mandate before sending troops out? >> i think it is a clear indicator we should be involved but there are other situations where we should not be. i supported our engagement in afghanistan and cosovo and i am proud to have among us in our great team of candidates the former commander of the army on the ground in afghanistan. the liberal party knows that canada has an important role to play in promoting peace and security around the world. i think we should have a role against isis but i disagree on the approach he had. mr. harper, hasn't seen a war he hasn't wanted to get involved in and that was clear when he supported bush's war into iraq and said in 2003 the canadians should be involved. canada has a role to play but it needs to be the right one helping local forces win the war for themselves. >> mr. harper, two of your opponents said you haven't seen a war you don't like. what do you make of that? >> i don't think this government has gotten involved in many military actions. we are involved in one against isis right now in iraq and syria. it is not true what mr. mulcair said. all of our nato allies support this and not only nato allies virltually all of the muslim countries in the region support this because this organization is a nerve center of a violent jihadist movement that is slaughtering hundreds and thousands of people but it a threat to the entire region and globe. it has singled out canadians by name and demonstrated the ability to carry out attacks in countries like our's. it would be foolish not to go after this group before they come after us. i am proud of the job the men and women are doing. i think it is widely supported by the canadians. >> a question one of my colleagues put to you. if not isis than who? >> the liberal party is clear. we support being part of the coalition against isis. we disagree that a bombing mission is the right way to go about it. when a prime minister choses to send men and women on the there has to be a clear plan, expectation of success, and reasonable justification of the specific action canada is taking. not just these people are bad, therefore we need to do something, it doesn't matter what. it means we have to be thoughtful because our allies and quite frankly canadians expect us to be thoughtful about our approach when we engage in international behavior. the other thing is if we are going to send troops overseas we need to make sure we are properly taking care of them when they come home. and mr. harper has failed our veterans by nickel and diming them and not giving them the service or help they need. it is something we should be ashamed of that this government is not caring for those people who fought, injured themselves and in main cases died under the flag. >> this government made record investment in veterans spending 35% more on the average veteran directly than we were when we came into the option. what we are doing with isis is the mission our international allies think we should be doing. these are the priorities. hit them in the air, help to train people particularly the kurds on the ground. mr. trudeau provides no rational reasoning why they should not doing that other than they should not go there. this is in the vital interest of the country and if you are prime minister you have to be able to make the decisions >> it is tricky. the question of who is our friend and who is our enemy. we are bombing in syria and we don't have permission. the civil war that has been waging in syria caused massive humanitarian crisis, four million syrians who have taken refuge in other countries. that was between the sunni-shiite where they are slaughtering each other and isis is taking advantage of that. are we going to help bomb isis, who some people said isis was probably helpful because they were getting assad. >> most of the world's crisis areas are in tricky parts of the world. >> it is very tricky. that is why we have to look at what isis is doing. why does this group of thugs put their horrific acts on youtube? they want to draw us into the region. they are following an ancient and not official text of which they claim is a muslim book of revelations that will lead them to certainly results. we are actually doing what they want. >> i have a question about different parts of the world. nato's article five says if a nato nation is attacked all nations must respond. would they uphold article five in eastern europe? >> of course. ukraine not being a member of nato i am not sure the question would pertain. we will support nato and are proud of nato. that is why i made reference to this cornerstone. the mission in iraq is not a nato mission. period. full stop. with regard to crane, putin is a danger. we stand firmly with ukraine against the aggression by russia. but there are things candidateicide and shouldn't be doing. our allies have a complete list of people being sanctioned. my question to you mr. harper is why are these two individuals being blocked by the allies and you are giving them a clear pass >> we have sanctioned a record number of officials connected with the previous government and russian officials involved in ukrainian territory. the objective in all of these things is making sure we do maximum damage to the country and putin while we try to minimize ours. we follow with the list and they do the same. >> these two individuals are on the list of our closest allies. mr. harper is refusing to put them on canadians list and now refusing to tell them why. >> on that note, we are wrapping up but heading into one final round of questions and that goes to justin trudeau. you had difficult decisions on war abroad and security at home, opposing the government's decision to take part against the action against isis in iraq and syria. why do these issues raise the most persistent questions about your judgment? >> the government and prime minister of canada is expected to do two things. the first is keep us safe and second is uphold and defend our rights and freedom. mr. harper doesn't think we need to do anything more to protect your rights and freedom and mr. mulcair with his position on counterterrorism law doesn't thing we need to do anything more. the liberal party is clear. we need to do both together. we supported the legislation because there were elements in there that protect canadian security and were committed to repealing the problematic elements that are highlighted and bringing in the proper oversight our allies all have by elected legislatures over the national security agencies to make sure we are protecting. bringing in sunset and review clause and making sure we are narrowing and specifying the definitions. we encourage the government to bring in specific amendments that removed a number of elements in it. we will continue to be productive and constructive in not pretending there is a political choice to be made. perhaps it was nice. perhaps something i put forward said we can take a responsible position at a time of politics of attack and division because mr. harper wants everyone to be scared there are terrorist hiding behind every rock and the other wants us to be afraid of freedoms. any canadian government needs to be them together and that is what the liberal party demonstrated since 9/11 and what we continue to balance to make it right. >> what do you think of mr. trudeau's opinion? >> i will let him talk about his opinion. but i will say our view is clear security and freedom go hand and hand. we know that the international jihadist movement we face is a serious menace is to the country. what we did in developing legislation is looked at what powers police and security agencies have across our allies and made sure we were up to the standard. we provided oversight. we have moved the oversight in a different direction. not having politicians doing the oversight. they are done by experts in the field, the independent committee, and they are chaired and those chaired by prominent, former judges. i think that is a robust system. is it because you don't know what it is all about? >> i don't support this kind of oversight. i support parliamentarians oversight. that is our job. when it comes to the operation of security agencies i don't think they they should be done by politicians but experts and handled by judges >> there is no expert oversight. if you listen to security exprpt perts and i urge anyone watching to go online and find the evidence of the mi-5 agent from the uk doing work with canada, this c-51 anti terrorism act makes us less safe. it is not confronting terrorism. it is very likely to make us less able to disrupt plot while at the same time eroding our freedoms. this legislation has been said to be dangerous and when asked abo by colleagues is there anything doing they should immolate they said absolutely not. >> we all agree we have to make sure we protect canadiacanadian terrorism. but we believe you have to do that without trampling on the rights and freedoms of canadians. a series of supreme ministers, court justice and top experts conquer that big c-51 represents a threat to freedom and right with nothing in return because there is nothing in there that wasn't captured by existing legislation. we have one clear area. the mvp will repeal c-51. >> and any legislation to give new tools? >> if there is evidence something is missing, the conservatives left out the domesticization and some of the code words has been worrisome. president obama talks about houses of worship and mr. harper points out and singles out mosques. he knows why he is using that language. he has a back benture that said muslim women should get the hell back from where they came from and he is about to sign papers electing that person. >> mr. harper, are you using code words? >> absolutely not. our mantra is the same on this. every piece of security legislation presented the ndp opposed. what we have done is things like allowing security organizations to share information, allowing them to intervene before plots develop, it is important. anyone who thinks this is labeling islam, muslims are the majority of the movement. minorities are a particular focus of our international efforts to make sure we protect people. not just in this country but around the world. if you are not prepared to call the threat we face by the name it is you are not prepared to con front it. >> this legislation fails to bring in any efforts, which the uk has brought in in their legislation, to confront the risk of radicalization. we can abort terrorist plots without this. we got the 18 in toronto, the aggressive young people about to leave montreal was all before c-51 was passed. c-51 creates a secret police are no reporting requirements and it will create separate security groups not going what the other is doing. this legislation must be repealed and then we should go back, look at the recommendations to anyone here, and i hope to be playing a key role in the next parliament. we must look at the recommendation from the inquiry and use those as the recommendation for the bases for drawing up legislation that could work. this is a disaster. >> i want to come back to c-51. are you surprised liberal members leaving the party to support the npd over this issue? >> no, i think this issue is quitely worked up about for a reason. one thing the liberal party is focused on is taking responsible positions and there will be people disagreeing on the left and right with the decision. i am confidant we have the right position here. we need to talk a lot more about addressing radicalization, working with various communities to make sure we are engaging in the kind of counter radicalization that other countries have done. with a country like canada, a country so strong not in spite of the differences but because of the differences we need to reduce the fear and work together to make the canadians safe. that is something the liberal party knows needs to be done. >> there are important measures in c-51 to stop terrorism. but the fact of the matter is, the reason we had such success in the country in breaking up plots before they have occurred and we know what some of those are, is because our law enforcement and security agencies are working more closely with community -- communities that are more vulnerable than anywhere in the world. that is why we don't have the kinds of problems in britain and elsewhere and these are the kinds of policy the government of canada and agencies are doing today. >> mr. harper's approach has left us weaker and less respected on the world's stage. for the first time since the united nations was created canada missed their turn on the security council. we were not thrown out by dictatorships but long term allies like germany that don't recognize the canada you are projecting on the world's stage. we can get back a to canada that is respected on issues of international aid and we will put back the aid budget mr. harper cut. we will protect and defend the canadian values on the international stage and respect our international obligations and stop working against the world, and stop working for the planet. i would love nothing more as prime minister, next to senator, to go the international conference on climate change in paris and do just that; get on track to deal with the very real issue of climate change. >> weaker and less respected on the world change? >> quite the contrary. according to a recently published study canada is the most admired country in the world because we take strong stands and do what we believe is right. let's talk about the security at the united nations. there is a movement to isolate the state of israel. this government took a clear position. we will not support that. it is wrong. this is the only country in the world whose existence is under threat. it is one of the best friend and ally the country has. >> i will take no lessons from anyone on the right of israel to defend itself but we take a balanced approach. we want a safe state for palestinians and a safe sate for israelis. that is the type of approach that is canada has always taken >> all parties are in agreement on this. we can talk about international relations. we have the worst relationship with the united states we have had in a long time. we need to work on that. >> we have covered so much ground over the last two hours and it is time to wrap it up with closing remarks. we begin with stephen harper. >> thank you, paul. ladies and gentlemen, this election is about who has the proven experience to keep canada safe and our economy strong. we know that beyond our shores the global economy remains in a state of turmoil and uncertainty. we have fallen oil prices, market turmoil in china, and another debt crisis in europe. but through it all, sense the end of the global crisis we have the best economic growth, the best job creation and the best growth in middle class income among many of the advanced developed nations. while other countries are descending into spirals of debt and deficits and tax cuts in this country we have a balanced budget, lower taxes, increased money for the things that matter, transfers for health care and education and infrastructure and benefits for family's like yours. the other parties want a different course. they would replace our low tax and balanced budget plans and want to spend tens of billions in permanent spending to definance the higher taxes and permanent deficit. they would take away in whole or in part the univerting child care benefit. they would have countries that have gone down the road of higher taxes and permanent deficits are failing around the world. you know that today, there is no better place or prosspect for your family than this country, candidate. on october 19th, i asked for your support so together we can continue to build the best country in the world. >> steven harper, thank you. tom mulcair is the next closing statement. >> i would like to thank maclean's and rogers for hosting the debate and thank you all of at home. in this election, there is a clear choice. four more years of stephen harper's conservatives or my plan for positive change. under mr. harper's plan income is stagnant and house hold debt is sky rocketing. mr. harper has the worst job record since the second world war, he has run up eight deficits in the row and added $150 billion to canada's debt. these values -- sorry, mr. harper's plan clearly isn't working. the list of conservative operatives under investigation is continuing to grow with some being sent to jail. the biggest risk to canada is four more years of mr. harper's government. it is time for change. change built on hard work and living within your means and accountability. these values guided my 35 years of public service and will continue to guide me. my number one priority is to kickstart the economy and get canadians working. we will invest in local infrastructure and help small businesses to create jobs. we understand that good jobs and a clean environment go hand and hand. i have fought for canada my whole life. i know that canada is the greatest country in the world. but a lot has been lost under the conservatives. i have the experience to replace mr. harper and the plan to repair the damage he has done. canadians are ready for change and so are we. >> i appreciate the opportunity to speak directly to canadians. i want to say it will be a shame if we don't have more debates because as comprehensive of the questions we haven't discussed social policy, how to respond to the truth and reconcile association, and how to include the medical system to include medical care. inequality. everyone is talking about the middle class and i support the concern. but the 86th wealthiest families in the country have the same combined wealth as the 11.4 million canadians at the bottom. we have to address this. so i ask you to consider the green party. i ask you to get to know us. we are not what you think. we are not a one-issue party or a one-person party. i am proud to be joined by deputy leader and bruce hire, and deputy leader daniel green. we have leaders from coast to coast. claire martin in north vancouver. people line gordon miller former environmental commissioner for ontario. we are running strong candidates because we want to work for you. we want to go work for you in a more cu -- colllabrative program. we believe in a canada that works and works together for all of us. help us now. >> thank you, elizabeth may. i have almost never seen a bunch of politicians stick to their time as well as you are doing. i appreciate it. justin trudeau you get the last word. >> mr. harper has spent millions of dollars on attack ads trying to convince you i am not ready for this job. silly as they are they pose an important question. how can you decide whether someone is ready to be your prime minister? here is what i think. in order to know if someone is ready for this job ask them what they want to do with this job. i have three children and want them to grow up in the world where we can be proud of. you need to love this country. it needs to run through your veins and feel it in your bones. mr. harper and i part way on many issues. but the differences go deeper than policy. mr. harper is dead wrong about one thing. we wants you to believe better isn't possible. well i think that is wrong. we are who we have. a country that work for the middleal class is a country that works for everyone. the world needs more of those things and after ten years of harper so do we. that is why i am in this. >> thank you, mr. trudeau. >> this concludes the first debate of this campaign. this whole experiment was a bit of a new experience for everybody concerned. i want thank the leaders for the leap of faith they showed when they agreed to participate. i want to thank the viewers at home and online. >> with congress on its august recess we are featuring booktv each week night. tonight, biographies and mem memoiars. we have many shows coming up. we have former nypd commissioner on his biography about his time in prison. booktv begins at 8:30 eastern. and on c-span, we are at the national urban league annual conference in fort lauderdale, florida. african-americans killed by police, the 2016 election, the voting rights act and edgeication are some of the topics. here is a preview. >> we must begin to prepare now whether it is the past action network or naacp that we are on the brink of a post-obama era. we have had a black president for seven years and a black first lady and a black first family. whoever wins this election will be the first white in the history of this country to succeed a black president. we have never been there before. so we need to see who is the e one. we followed eight years and we will not turn around what he began. we don't intend when the black family leaves the white house that black concerns leave the white house with thep. them. >> watch that event tonight beginning at 8 p.m. eastern on our companion network. >> tonight on the "the communicators," kevin ashton on the creative process and how that process takes work. >> why did the wright brothers fly first and what process did they use? they were not the first to build the idea of having a flying meshem machine and not the first to try. why did they succeed when everyone else failed? they tried to understand the problem and being creative is not about having ideas in the shower or a moment with a lightning bolt of inspiration. it is about solving problems one step at a time. so understanding the problem with a piece of paper, which is a problem of balance, was the key for the wright brothers starting on their course that ultimately led to them flying >> kevin ashton, tonight on the "the communicators" on c-span2. next, a discussion on how homelessness can negatively impact an individual's health and health care outcome. the policy director for the national health care for the homeless council is one of the guest. it is hosted by the alliance reform. >> good afternoon. we should continue to try to find seats and we will try to get started. my name is ed howard. i am with the alliance for health reform and i want to welcome you on behalf of the directors. our co-chairs senator cardon and blunt to the meeting on the e emphasis of government and housing at the state, federal and local level. this is the first in a three-part series that will explain the intersection of health and social policy. on october 9th i believe it is, we will be looking at this. and in december we will look at the emerging issues in health and incareration which is a growing area of concern and activity -- incarceration -- there is a health between various health deterants and we will look at the nature and strength of the connection in this briefing and the others. something you may have seen yesterday, new york city mayor announced a $22 million program to connect more homeless people with mental health care. i think just another sign of the growing activity. today i hope we will shed a lot of light on that. our discussion centers on housing stability affects outcomes and health care cost and look ad medicaid's role in addressing this and how much flexibility there is and allowing housing to be streamed. and importantly we want to look at the obsticals to making the problem areas more compatible. we are pleased for to have support by america's largest private insurers that operates medicare and other programs in two dozen states. >> >> and having them brought forth to respond. at the end of the briefing there is the evaluation form in your packets that we very much appreciate you filling the house so we can include the briefings to target the needs of the folks who need the guidance. indefinite dash let's hear from our panel. to give them introductions but we will start on my far left the director of policy at the national health care for homeless council. barbara is also works of the multi level respective how to deal and how to highlight the connection between health care and housing in general, why it is important and the state and local level to address per then senior advisor for the hud secretary and jennifer well explain those activities to describe how her agency and others are collaborating on housing issues. but hammer is director of department of health care policy and financing with the medicaid and chip programs and will tell us about the efforts to bridge the policy and what gets in the way in the final panelist is mr. o'sullivan a family physician and a founder of circle this city that brings public and private sector together with those under homeless and she will describe the support of model and what gets in the way of this approach. become to the program that has substance. barbara? >> i really appreciate so many people being here today and it is a testament to a growing awareness have health care is changing in our country and in particular the impact that housing has. the national health care for the homeless council hopes those homeless patients that they serve about 250 nationally and over 1 million are seen each year in the depth and breadth of their needs specifically because of the lack of housing is an issue for the larger health care industry. one of the things that might not be intuitive is housing and health care. back and '80s the instituted a steady and they found three major findings. so the main causes of homelessness we have a spiral of people who have an injury or illness and able to work then eventually the work kiddos away or you are fired or laid off. pretty soon you cannot make rent or mortgage to move in with family or friends then use slide into a shelter situation. we would see them regularly. we also see that homelessness causes for health. to imagine living on the street or in a shelter is stressful if you didn't have issues before you would tend to if your help -- homeless it is very difficult to be exposed to extremes of weather without getting hospitalization and emergency visits are frequent. high blood pressure of you were not stressed out before he lost housing you are after and depression and mental health issues tend to be developed if you do not have them before you would develop after or they are exacerbated. you also tend to think of lack of housing. we are putting billions of dollars into our health care industry and for europe none of that works as well as health care providers. when someone is living on the street every time we take someone threw a recovery treatment, only to discharge them to the street, we have complicated and compromise the treatment. when we discharge people from hospitals to a hospital to the streets the inpatient stays the wound care is now compromised. this is what is bundled up together into the intersection of health and housing so we need to appreciate how we can rectify that. one of the things we are seeing as we represent the doctors and nurses and case managers and the work force that goes behind caring for these patients, not surprisingly b.c. communicable disease sur's respiratory illnesses, everything you would expect with infections from cuts, diabetics and needles that is hazardous to your health. the rate we replace medication is astronomical because of the rate they are stolen. lucansky your item save for cannot keep medication refrigerated. how many times have you gone to the doctor and have a prescription given to them that makes them visit - - visit the bathroom or often? that isn't possible when many places don't a for the homeless people a place to use the bathroom so we see higher rates to be extremely indecent and rehab local ordinances that criminalize that activities though we have health care providers to say i didn't take the medication otherwise i would be arrested cry was afraid i had no place to go. my needles or medication was stolen. this is what we hear. so when we look at the literature the people who help our homeless between three and six times of what everybody else has. we still have asthma and diabetes and hypertension and heart disease but still with higher rates. we see a lot of intensive need to coordinate this care and we see both extremes of the use of the health care system we're getting a lot of attention of the high end user to put a lot of money into a small number of people to stabilize but also those living on the outskirts that had intensive needs in the mental health or substance abuse treatment area. those that are very fragile and in need of care. looking at hospital systems they are strapped. water use supposed to do with no safe discharge option? for a client that is ready for discharge? it is illegal to discharge to the street but anything else what do you do for somebody who doesn't have a place to go? these are the real issues people are struggling with as they find capacity to be safe and ethical treatment. we also see a lot of people that when they're ill it is very difficult to get out of homelessness to work on housing if you are fighting eviction our mental health is hard to get out of the shelter or off the street. he even with the health center population people who are homeless at disproportionately high rates. so that brings us to support of housing. when we think what is supportive housing it is helpful to think about a traditional model that emphasizes recovery first. traditionally we require people to get clean and sober and enter into treatment before we get them into a housing unit. then maybe one day you can be in independent housing. it is hard to get clean when you live on the street. so this hits that model is not time limited. any of us can go home and have a drink but it needs to be an opportunity to work with people where they are so we have that stability so people have a place for medications or a place to put the appointment card or a stable place to visit them. out reach cannot find them if they are shifting and the encampments change. haori supporting housing in this way? team base services is the secret when you combine the stability of housing with health care services, we can really help people to be stable in their housing. this is mainstream for seniors and disabilities. my grandmother can have meals delivered to her in home care with bathing and keeping the house clean that we take for granted. to think about extending that to this population's we're supporting the housing and services that people need to keep with the same fame. relapses part of recovery. we need to expect this recovery of mental health and addiction in is not black and white and yes and no but it is a struggle. when people are in a zero tolerance, even though one slip up would jeopardize housing to be back on the street so it is important and again there is no requirement for sobriety but we have found people are excited that now so many things look possible. to evaluate the effect of the peer review literature and consistently what we find is housing improved health and the health outcomes lowers the total cost of health care and this is where we need to be to rethink housing because your so focused on cost so where is it to make the inroads and partnerships? so with those consistent findings we want to focus on how to bring these two sectors together because of what we need? there is opportunity at the federal and state and local level for all states are working on strategies and homelessness to read proof of also a greater determinants to improve health. but one thing is important to remember is we need federal support for the housing piece that goes along to make this work. my colleagues will talk about what they are seeing in their sector but the cuts that are required by sequestration, if we don't have the housing support to put people in no amount of services will make this work well. we need these to come together also for all of you who are health staffers or housing staffers coming get to know each other you have a lot in common with we're not working of the federal level but asking people to do at the local level. a couple of things i would recommend. but we're trying to build the bridge between health and housing and as health care providers we're in a rapidly changing environment medicaid is one area but this system is changing as a whole to focus on the outcome and costs but also vulnerable people to get them what they need but nothing works well if people are living on the street as a health care provider. we wanted reorient as a prevention and my colleagues will talk about to build the bridge that really is an illustration how we're trying to work together to make this model work to achieve the outcomes we're all looking to achieve. my colleague is year if anyone is interested to learn more. he can get back to but we appreciate to be here today. thank you. >> jennifer? >> i am the hud secretary senior adviser i am the one person who knows the difference between medicare and medicaid every day. you know, what i and talking about. [laughter] my background i spent the first 10 years of my career in managed care largely medicare and medicaid managed-care and in that work the was first brought to a table to consider the relationship between homelessness and health and the impact that housing would have if with health care utilization and spending but i have been during that ever since the last 18 years for cry want to assure you there is the unprecedented level of collaboration between hud and hhs not because that is my job but it is the case. hud is talking to the center for medicate almost every day and a center of innovation and we talked to at the administration of children in families almost every day. and though sometimes it feels they are miles apart but i want to promise that with this administration there is an unprecedented level of collaboration. there is a simple fact houri invest health care people don't always know because you operate in the world lived in chatham of programs and mandatory budgets. it is the only means tested that is not entitlement. and somebody comes eligible they get it. if you fill out an application for housing voucher you get in line. when we ask congress to invest in more supportive housing day worry about the renewal burden that it increases the total budget in future years something like to call keeping people in their homes. so cut services for housing that medicaid could pay for. it has a lot of financial incentives to be a more affordable and excessive and supportive housing but the budget environment we're not doing what we know works or anything to scale that matches the need but that is why i am excited to be here today because a short interest could help create that consensus that we need. so thanks for being here. and allowing me to be on this panel. sold aging and disability and homelessness. americans are living longer and the baby boomers will test our commitment to the relationship between housing and health. ages the great equalizer we're more likely to have chronic health conditions less mobility and live alone of harvard joint center on harvard study is the number of households eligible for rental assistance will increase by 2.6 million people between 2011 and 2030. with hud we provide rental assistance at 132 million seniors one out of every three seniors who is in, eligible. so we would need 900,000 more subsidized units by 2013 just to keep up with one out of three people getting it. but the have not made significant investments for some time. think about where you live today or parents or grandparents. less than one-half of 1% of existing housing is currently accessible to someone who uses a well up -- wheelchair only 5% for someone who has mobility impairments and only 40% is modifiable. most existing housing is not designed for them to aging in place safely. so imagine and 20 million people over the age of 80 fall and cannot return to their home or they don't fall but they cannot afford were they lived. where will they go? how'd we have a strategy for aging in place if they cannot afford or navigate? the health care system had a huge stake with the accessibility needs yet there is not consensus the government should be making. a lot of the work with hhs is around disability the money follows the person through the new and improved program section 811. divorce is partnerships between the agency in the state medicaid agencies in some places like colorado it doesn't have to be forced but beverages multiple sources of funding to create integrated housing to provide services that have a deep rent subsidy through hud with a few rounds of funding 35 states now have the money the last round refunded $150 million for about 4,000 units it is a drop in the bucket but the health care system argue has a huge stake to create more integrated housing options for those with disabilities that otherwise to be in the institutional setting but there's not a consensus that this is the investment that they should be making each year and is not in the markup for the year 2016. i appreciate barbara covering the arguments and sister adele will be the closer but i want to add a couple of things. the president's budget request have included investments to create sufficient supply of supportive housing and homelessness in america. in 2016 to create 25200500 additional units to leverage the creation of supportive housing as a proven intervention the works for people and improves health and reduces the necessary er visits. so the health care system has a huge stake to create a supply of housing to end homelessness but there is not a consensus this is an investment of federal government should make. we are learning something with the work of the veterans homelessness here there is a consensus on investment to combine rental assistance with case management. we have seen a was a third reduction in between 2010 and 2014 and we're on a path imagine if we again investment aligned with medicaid to repeat with individuals with disabilities to have lived on the streets for years or decades. my focus is to think of ways we can better align housing and medicaid i am new threshold with a new bulletin that was published there is a link in the documents in your packet. i am increasingly meet state medicaid directors to understand that if they achieve the goal of health reform, they will neil allen dash need to deal with homelessness with a new best friend. this document helps to bring clarity to something that has not felt clear. if housing is over here and health care is over here, what is in the middle what can medicaid pay for? i believe if pain for the services that it can pay for we will have better health outcomes for seniors and better options for individuals with disabilities and to end chronic homelessness and if it became a major player of housing we could build that consensus needed to make that public investment necessary to help seniors aged in a home that they could navigate and afford. they have the right to live in the integrated setting with more choices of where to live then to make housing available because they value that partnership. to date that conundrum is there are services medicaid could pay for. has a lot of financial incentives to be more affordable and accessible housing in that budget environment but that is why i am excited to be here because your understanding of the relationship between housing and health then your advocacy is supportive housing for older americans and individuals with disabilities including folks with disabilities living on the streets, could help create the consensus we need to make the investment that no matter. thank-you. >> let me just ask a clarifying question. talking about the services that medicaid could pay for and i wonder if you could be more explicit to say a couple of words what is stopping at that from happening now? >> for example, with our homeless assistance program spend over $400 million per year. we only need to order $65 million to create more support of housing to end chronic homeless as but we spend 400 million on services. that is everything that medicaid cannot pay for like employment assistance but a lot of that is exactly does type of the engagement and assistance that is described in the new related bulletin the biggest barrier is that states don't know what will be approved or we're to ask for. for everybody is afraid to say they need to pay for housing we save medicaid should pay for health and the services that we're doing pretty naturally now to keep cramming out of the nursing home or to keep some the outcome of the institution needs to be extended bear also paying for services coordinators is senior housing and in public housing and a lot of that coordination is wellness activity so we don't have an ambulance pulling up every night and keeping people in their homes longer. >> very good. gretchen and? direct thanks for inviting colorado to participate in this very interesting conversation. colorado is working diligently on this issue and it is a privilege to share with you the things we are doing. but first of a bite to provide context everything we do with our state government at this point in time is driven by a governor's platform for health that we call the state of health our goal is to help the state in the nation and we take that goal very seriously not only because we have a great place to live but health disparities within the communities that are holding us back and we're working hard to move forward so it is around the interconnected nature for economic growth and social conditions to work more effectively for healthier people to create a health care business environment. when it looked at those listed we we can put the right services supports efforts in place to make colorado the healthy state in the nation the is the background of the best help them the best care for the best value that is our translation and create a commitment starting with prevention and robust when they think of those issues that we discussed today the nature of the health care system to need health insurance most of the time to access those services to make sure we have the capacity to meet this is since of colorado air their needs for also what could have better value we invest a lot of money in our health care system and we have some opportunities to get better value for the dollars that we invest in their requires infrastructure like health care capacity, a primary-care medical homes, integrated care between physical and behavioral services summary don't have one person with one body going to three different locations and also information technologies of the state of health is a high holistic view of colorado and how we move the agenda for word. redid expand medicaid in colorado with a coverage incapacities area of focus in september 2013 colorado has 750,000 cholera radin's covered by medicaid now we're at 1.2 million who get health care coverage through the state medicaid program. 52,000 pregnant women and children is our version of chip. you can see in the breakdown there is a diversity of breakdown and it has been a celebrated by the expansion expanded early for those living at 10 percent of federal poverty. that is $11,000 a year. we expanded at 10% or less and then builds on that as we would move into january 1st of 2014 it was an important step to understand the needs how to best engaged with them and support them to have access to coverage and what other types of services of the expansion is an important piece of our working and coupled with that is the additional commitment of the governor's office there is a specific individual in the governor's office with our current governor was mayor he had a very important platform and that has continued into our administration. the focus has been around me and that has required us to look at the capacity of our housing system and how we can identify existing resources and whether innovations to read a? colorado is a very nice place to live i have lived there almost entire life and it is also expensive so given that it is an issue that is directly impacted by the components of of marketplace, it is a challenge at times in the expensive housing environment we have one of the highest real-estate markets in the nation to figure out how affordable housing can be made available the dual focus of the health platform has set this up very well to look at how we can begin to expand the relationship between these two areas. health and housing is an important piece of what we're working on. to be engaged in discussions that created a crosswalk of how can we be sure we're using investments and appropriately so the medical related supports and services are paid for in a way that makes sense and others can be leveraged in the same way? i just want to take a moment at the findings looking at the fiscal year 13 / 14 that looks at the first six months of the full expansion and there was about 37,000 enrollees who reported homelessness. 24,000 reported for the entire year and others talked about at least at some point. that is an important piece but when we think of homelessness or coverage, it is a point in time and peace there is a period of time you were homeless or when you have coverage than during the day you pick up the survey that is rare you are but that is not for the entire year so it is an important piece to recognize that variants. when we do the analysis it was $160 million and through this exercise we began to break that down and looking at the top decile of the 3200 most expensive was $97 million we talk a lot about money but we can also recognize those people were very, very ill and probably did not feel very good. it is important to recognize we have an opportunity not only to save resources if we do this better about how people feel better and have a better existence as they move through the world. it is a very important piece from the overall health perspective and we want to be the healthy estate in the nation that is everybody. it is the important balance with the experience people have. as we hear about the new opportunities and the clarity from cms committed is the chance to have more clarity as rework to see what can we do to bridge health and housing to not only address these individuals but the more permanent structures in place overall. but these services can exist at the state government level. we have created a cross agency work group set has a state medicaid agencies and that group meets twice a week and some of the basic language of bureaucratic programs have their own speed can really use acronyms so you have to step back. what do they mean? is an important clarifying of language and also to recognize if it takes less time to know how to interact with one another in the 64 counties across the state of colorado, obviously there is some confusion and opportunities for better education. that is where we're focusing energies now to help providers on the housing side and the health care side understand where the opportunities to work together and how can really bring in the alignment and this energy is available to all of us also the way for authorities so there is a recent document out related to substance used disorder that is a piece we have not highlighted but important how those services can be delivered. and the technology pieces a medical management information system then we go through the procurement to see connection so of technology could help us so i would conclude the reality of the people at the heart of efforts. we had the chance in my former life for those living in affordable housing and their health care experience is. one of the most heartbreaking things was the lack of dignity they felt they were afforded from the health care system. it was a gift that they had the chance to be there if they were smarter they could figure around how to navigate that i frankly struggle with. so what we concluded if it doesn't cost any additional resources to have respect and dignity so it is important to think through these but there are some basic things we can do to help improve their health and mental well-being with just saw recognition they are hard issues and the folks in the middle of the support and respect. >> thank you. dr. o'sullivan. >> good afternoon. i am very happy to be here today. i speak from another additional perspective. i am a family physician and care for exclusively homeless population. since 1996. i experience every day to get good patient care. the trickle-down effect of policy and spending decisions in the lives of my patients. and how our ability to make good policy and spending decisions influences the health outcomes of very real people. i come from arizona for arrival speech you about several local situation is somewhat unique. arizona is the medicaid expansion stage i am happy to say but still there is a legal challenge pending in the courts with that extension. we have other successes have a bike to tell you about and one is a increase chronic homeless this by 15 percent between 2013 and 2014. on a note i experienced personally, we began in the phoenix area that is a large and sprawling county with the homeless population of approximately 17,000. i started a nonprofit called the circle the city and we did as a grass-roots community effort to bring people together to meet the incredible need of those who were too sick, a frail to be in the shelters and on the streets. in 2012 we open up a 50 bed facility in the phoenix area called medical respite that word is confusing but it is recuperative care for those experiencing homelessness. think of it as bridge housing with very intensive medical support. this has been a crucial part of our ability to provide for the second stanford realistic and most colorful. another a good piece that happened is the number of supportive housing units is growing. in maricopa county 1600 units were funded for individuals with this serious mentally ill designation with a continuum of care who funded the rental subsidies and medicaid funds the supportive services through the regional public private initiative, it was united way to bring partners together, another 1,000 units of supported housing were targeted to chronically homeless individuals in maricopa county. however, we still have a supportive housing need in resource challenges. we think it would take 1,000 more units to end chronic homelessness in maricopa county. the arizona medicaid plan covers say comprehensive bundle of services. the flip side of that is in a supportive housing they're only available to persons with a serious the mental illnesses in the nation. our nonprofit participated in a pilot project with a large medical center. free cry users of think he is mitt is an acronym a tremendous active and wonderful partner to get support of housing available to us. and with this pilot project, we engaged the most frequent and expensive the homeless you divisors of care. we engaged, offered services of the medical respite center chair stabilizing and assess, and then quickly moved to supportive housing. the vouchers were donated from several agencies in the community. that pilot project realized a 73% reduction of and riches he ruth visits and 74 percent reduction of the inpatient utilization after placed in permanent supportive housing. the diagnosis is homelessness. these are the patients we took care of through the private. they did not have just one chronic diseases. son had to. most at three or four or five. that does not take into account the diabetic foot ulcer or the heart failure exacerbation, the crisis for which people cycle in and out of the emergency room care. why do people cycle in and out? in our population these other reasons that we believe. and as you can see, the last one is the primary care system might not be responsive to the population in issues or the multiple issues that barbara talked about earlier that are simply the reoccurring hoped -- phenomenon to be homeless on the street. i would like to show you a case study we call him mr. 280 was well known to the phoenix fire department because he called 911 all the time for transport to local hospitals adding that that he had 280 visits but with the hospital that we worked with, he had been to the emergency room 192 times between 2007 and 2013. we engage him and brought him to circle the city respite center for three weeks and discharge him to permit supportive housing. this is his hospital bill is just at st. joseph. page one. page to. page three. page four. page five. page six. page seven. page eight. page nine. page 10. during that period of time, he had 192 visits to the emergency department common but not one in patient admission. i can tell you when we actually engage mr. 280 he was almost living in the hospital parking lot. total account charges $350,417 at one hospital. this is the graph of the emergency room visits during that period of time. there is three places bear when he was not in the emergency room for the month and we can show you a three month shot that corresponds to those months when he did not appear in the emergency room. since being house he has been to the emergency room twice. both appropriate visits. he had never been admitted to the of hospital he is stable house and has remained over that period of time. he is receiving care and the traumatic brain injury clinic at the neurological institute coming he got his food handlers card and employed part-time at a local restaurant. so what are the challenges on the ground? i thank you have heard talk of care coordination and. we'll love it when we can get somebody into permanent supportive housing because we have that opportunity i will get tough little sore heel that he is in housing i will not if he is under the bridge for in the shelter. we need to coordinate services that we provide for but we haven't figured out who's responsibility that will be. that is another issue where we have to work together. we have to prioritize the support in terms of medical needs. if you haven't seen the work from dr. o'connell that medically vulnerable are dying on our streets with pretty good data to show that persons with chronic illnesses, and medically vulnerable wilma survive. but yet as our electronic systems, we have to learn how to cross them for those resources that we have to the person that needs them the most and one thing we are interested in is to develop new end innovative models to deliver primary health care efficiently so once we get people there, how do we deliver the care in the most efficient way possible? to retake the services to them? all of those are possibilities. we know it is important to place people immediately. they will not get sick for one thing but when we can locate the person that needs the housing we need to put them there are obliged to put in a plug for the medical respite care for the homeless as a pivotal point for the patients that are too ill can use medical respite as bridge housing. housing is health care. if we could increase availability of those units we need the vouchers and the services. anything we can do to incentivize our states with permanent supported housing, medicaid is wonderful. but medicaid alone cannot do it we need the support from the mental-health providers we need housing and when we can get those wraparound services those positive outcomes people think not possible i am here to tell you they are possible. thank you. >> that is terrific. now we are at a point where we've above to scheerer your questions with a card to you can fill out and hold up. but sister, can you talk about the kind of money coming which pockets were you able to pick to put together an incredibly impressive array of housing with services that have allowed you to make such progress? >> as far as housing is concerned, through continuing of care also from valley of the seven united way we to put together funds from department of housing from the state, of a couple of the city's in the maricopa area. those are the vouchers to direct for the health care folks in the room confused by continuum of care as the hud program i will just jump in. the homeless assistance program is delivered in communities through collaborations that we called continuum of care i wish renamed is something else it is confusing so when she said she got many, that was probably rent assistance and may be capital development through the hud homeless assistance program that is exactly the same place we are trying to get the funding to do additional units like you say you need for maricopa county. just a little plug. >> please identify yourself and keep your question brief >> 8m media. so what experience to any of you have for those who have gone on medicaid as a result to experience a natural disaster to lose the housing they had before? >> i would love to hear talk about what i observed in new orleans. it is timely with the anniversary of hurricane katrina. the number of people who lost their homes was tragic and a devastating but what they did with the rebuild was amazing and because there was a lot of flexible disaster recovery money, low income housing tax credits that is the biggest producer of affordable housing with block grant money that is the most flexible mini and housing vouchers and shelter care place vouchers of with disaster recovery many the amazing thing they did is use the community development block -- block grant to play for services will be created housing and the shelter vouchers to deeply subsidized units while they built a medicaid system to pay for those services to become the triage process to identify those with the vulnerability i say that even interstate when the governor had chosen not to expand medicaid but it shows what is possible win their you strategically together. i hope that reflects on what you are asking. >> i should call attention to what is on the screen an incentive program of powers along with several friends to get you to fill out the blue evaluation form. if you do in sufficient numbers that we've reached a 50% participation rate, the alliance will make a contribution to the community of hope you're in town that deals with some of these problems including homelessness and health care on the ground so don't leave without filling out your evaluation form to make sure the person next year of bills that out as well. >> as a shooter social medicine and community health. this panel is a great example and yet i am not hearing a focus on standards of care that we would expect all hospitals and health care providers to be aware of. mr. 280 that sister sullivan introduced us to says hospitals taking advantage of the medicaid program to extract as much money as they can from it rather than identify the source of this man's needs to make recommendations to address them whether through the resources of the off hospital of the generic community. i think the colorado story is interesting to be the healthiest states that means not just a healthy state for homeless people but for all people. where are the recommendations on how the health care system should be integrated into the social determinants of health with housing being the example? shouldn't we require standards of health when health care providers should be forced to identify the causes of the problems they are expected to treat? i think it is a great opportunity to raise those issues to have generic solutions and not just be proud for a certain segment of the population. >> i will start. i completely agree and appreciate your passion. we are trying to get the health care system to the place you just describe not just for special populations but for all of us. sabir all looking for the outcome driven, how are we getting healthier and how to read demonstrate that to put the resources behind that? and me the actual integrated system that has resources to to live through the kinds of care that we envisioned as we try to build the capacity to get there and that hasted deal with the partnership described among people who are in charge of the social determinants good jobs and stability and health. as we talk about investment in housing in the partnerships we need to have it is informed by recognizing this man did not have housing and it is contributing to the 2881 dash emergency room visits so how does that get him into housing? if that is the resources that are woefully insufficient in every community in the country so i applaud what you described as well. we have to get there so those investments that the federal level to be honest about. does that answer your question? >> it addresses it beautifully. >> one of the ways we see movement, there is the broader recognition with people's life circumstances but in addition to the medicaid delivery system for physical health systems put with regional and duties that they get additional resources we pick though strategically to begin with regression to a the hospital with the use of high-cost imaging and nobody likes to have anything that is not needed twice were to wait so and had both components. so to recognize there may be an underlying social factors that with some attention and we could meet these key performance indicators so postpartum the there are homeless families as well to believe they can broaden the family's needs. >> to follow-up with a point this population in was ineligible for medicaid up and tell the point of the affordable care act extending medicaid threat was not even part of this system spirit never eligible but probably not tynwald. >> correct. only if you had of vast majority ever seen go non disabled so this is the first time that we get them into a system to look to their needs. >> for mr. 280 that was before medicaid expansion so he had no insurance. >> my name is eleanor with the infectious diseases society. so as barbara and sister adele were speaking of supportive housing with permanent supportive housing so to save them sustain their own housing in are there any metrics to determine when somebody is able to phase out. >> and how's my dash happy to start that one. that was really created to distinguish a from the paradigm of the day and the you could stay as long as you needed to. and to not have day clock ticking is a supportive recovery. the stress associated to know that you have to have cracked together in a certain period of time and go someplace else it was counterproductive to have a long-term stability.