Its exactly the reason i gave up my cell phone number during the First National press conference in september and i get calls every single day from veterans and to listen to them. Because youve got to keep that this will put the above were trying to do. Its all very personal. Thank you for your dedication. Thank you, mr. Chairman. I do have some questions that i will submit for the record. Thank you, mr. Chair been. Also secretary, thank you for being here. Appreciated. I visited with you before about legislation that i put forward, the veterans access to extended care. And its all about making sure that we can encourage Nursing Homes to take va reimbursement for veterans by limiting the Small Business contracting requirements that are currently under when they take va reimbursement but that they dont have to deal with when they take medicare reimbursement. Thats a burden that really makes no sense for them. They even have to undergo a separate so theres a lot of red tape, a lot of compliance issues so many Nursing Homes will not take the reimbursement. Just ask you to comment if you would on how you can help advance that legislation so we can get it put in place. We are very much in favor of it so we want to talk to everyone whos going to vote and make sure they vote in favor because we think thats the way to go. Weve got to focus on their outcomes, veteran Customer Experiences and theres just so much red tape thats getting in the way of it. Our people try to work in a system where they are prisoners of the system rather than working on working veterans needs so we are very much in favor of the legislation you have described and want to work with you on it. Thank you, mr. Secretary. I recently had a roundtable in my state and many Nursing Homes were represented there and they said if we could get this passed that they would then look at taking the reimbursement so i think would be very helpful and appreciate your willingness to a. The second question i have for you is its similar but it goes to the Health Care Medical care from local providers. Youve touched on here in a number of your responses but im a cosponsor, senator moran is the prime spots and theres other stuff is on the bill but similar. Its a veterans access to community care. Youve touched on that and some of the cost factors, but essentially the idea is to get veterans care closer to home when they have to go a Long Distance to a Health Center. They may have a seat block but for example, in my state we have one va Health Center. Exhibit good Health Center, covers north dakota and most of western minnesota. They do a good job but its a long way from an 800mile roundtrip from williston which is the Fastest Growing community under 50,000 in the country now, maybe over 50,000 but when they cant get that serbs were real geographical issues here. Your thoughts on what we can do to address that in a way that serves our veterans and then makes sense in terms of dollars and cents, affordability. I think job one is to really execute the redefinition of the 40mile limit and do that as quickly as possible so we can really determine how many people will want to use community care. We really dont know today how many people who want to use community care. We know that the redefinition of 40mile limit will virtually double the number of veterans will take advantage of it. Thats what we think of me defined data. Secondly i want to redefine or reinterpret the geographic burden so that we have more flexibility, i have more flexibility to provide the ability for people to call it that geographic burden and go to community care. The 13 were looking at which we talked earlier is whether or not we look at whether we define it as a va facility that can provide that service or a va facility that doesnt. Opening up that aperture could potentialpotential ly be extremely costly as i said earlier, could be 10 billion a year to 40 billion a year. Of course, the whole choice act, this part of it was 10 billion over three years. Thats a conversation we will have to we need some experience to be able to develop that algorithm. And i think, you know, really unimportant air to figure out how to do this. Because again if they are within 40 miles of a va Health Center, well then that 40mile rule works pretty well. But if you have these really long geographic distances where they have a cbot, its a real problem because theres a big difference. If they have to have openheart surgery, well sure, maybe that trip i understand and so today but theres a lot of situations where theres services and between what he cbot can provide and what a the Health Center can provide what actually would be costeffective for the va, too because of that better made to travel one day get the surface of the second second day, traveled with her day and youre going to pay for both the travel and the accommodations as well as the service. Indicates that a very senior person, think about the burden of the travel. For a younger person whos working they are not taking three days off work. So its not only about figuring how to do this for the veteran i think it can be costeffective for the va if we do as you say, if we figure out the numbers and figure out how to do it. So theres a difference between a Carte Blanche and doing it in a way that makes sense. Thanks for help understand look forward to working with you on it. Thank you very much mr. Chairman. Mr. Secretary, good to see you again. Last year i introduced legislation to expand the Caregiver Support Services that the offers and has finally made the full Program Available to veterans of all areas. Im going to be reintroducing that legislation tomorrow. Senator collins is my cosponsor on that and i want to work with you to make sure strengthen the program and make sure it has the resources it needs to take on an additional workload. I really was happy to see the department requested a significant increase in funding for the program and have also asked for Additional Resources for the department who are more caregiver support coordinators. I want to ask you today do you know how many more caregiver support Court Invaders you think youll need over the next two years to support the current needs . If you take care of new veterans airareas come into the program . I dont know exactly i do know we are very supportive of the legislation you have written. We think pre9 11 caregivers should get the same benefits post 9 11 do. Ive spent a lot of time with caregivers myself there from the Unsung Heroes of our nation. Many of them have to give up their jobs and many of them have to purposely not take on work and not take on income because then they would fall out of the program. So its a real conundrum for them and its lifechanging for families. Weve got to do this and we are you take it on and we are eager to hire the people we need. Ive been to several college campuses. There are people who want to join the va to do this job. They are really eager to. We would love to work with you on legislation. If you can let us know what you think youll need over the next few years particularly with this edition of this i think is absolutely vital so thank you. I also want to ask about the spokane the Medical Center. As you are very aware the emergency room at the Spokane Medical Center has dramatically cut back its operations because of staffing problems. The Medical Center has repeatedly pushed back the date to resume fulltime operations and now ive been told it isnt going to be until next fall. The slowpoke this book in va has also recently asked for a surgical complexity rating to be downgraded and im concerned about that request and the potential impact on access to care for our veterans in that region. Last year i asked citations us the end the intersection whether the plans to reduce programs and services at the Spokane Medical Center and they assured me they were not. Yet we now see this assembly being downgraded. The Medical Center is not getting the job done so want to know what youre going to do to restore Emergency Services and physical care for the veterans everyone is spoke in va. One of the big challenges weve had and we discussed this previously is actually recruiting top notch i can think of for 10 years. I meeting with the college of Emergency Physicians either next week with a week after that to try to see if we can help with them. Deregulate it also has some ideas about how we might work with some hospitals and would also raise the available salaries so we can be paid to people there. Ultimately, if we cant recruit top notch talent i think were going to need to export some kind of partnership between the spokane facility at local hospitals visavis emergency care. Will look this up an ongoing forever and if nothing resolve and its a huge issue for spokane veterans so i want to talk to you again, mr. Secretary, weve got to get this result however we do it. While i know its been going on forever and we accept full responsibility for it i have been to over a dozen medical schools recruiting doctors. Ive been to the osteopathic convention recruiting doctors. We are the canary in a coal mine. We are seeing the problem that exists in american medicine. We need more primary care doctors, more doctors who live in rural areas and we need more Mental Health professionals. We are working extremely hard to do that and to find them identify them and convince them and give them a monetary incentive to locate there. We will continue to work hard and to get that spokane facility up and running. I really appreciate it. One of the question. I just have a few seconds left. Right now the Veterans Affairs committee is holding a hearing on va service for Women Veterans. I want to stress to critically important it is for the va to prepare now to meet the needs of the growing population of Women Veterans. I was really pleased to work with senator how to introduce the womens access to quality care at this year. That legislation is going to go a long way in helping the va provides safe, private health care for women. Va already has a cyst backlog and construction but its a number of Women Veterans, to be a need for more Space Dedicated to gender specific care. I wanted to ask you what the va is going to do to make the treatment space for Women Veterans over the next 10 years. Some of our budget that was cut dramatically in the house markup was slated for womens clinics. We are installing womens clinics in our facilities. We are hiring the gynecologists and other specialties that we need in order to staff those clinics. And to us this is critically important. 11 of veterans today are women. Its going to go up to 20 by 2017 or so. So got to get this done. Many of our buildings as i said earlier are over 70 years old. Some of them they dont have a private space for women. And they have single gender bathrooms. Thats where construction budget was as high as it was. Mr. Chairman, im out of time. I will so that the rest of the question but i appreciate that. I want to keep working with you on this. Transport and talk about the hippopotamus smoking in the room about denver you guys asked for 5 billion to help fix denver. Where to be go from there in your view . Where to go in terms of what is your in state for denver . Denver . Our instant forgiveness to finish constructing the medical complex. We would use i would say finish constructing the medical complex under the supervision of the army corps of engineers. Yes. They are on the project and they would complete the project with us and with plenty of the army corps of engineers in the future for Major Construction projects. I will make it simple for you. My position as Cory Gardners position to make sure you work very closely with senator gardner. We agree. Thank you. In fact the deputy secretary was out in every aspect has been i think the seven times since hes come into possession. Lets go with senator baldwin. Thank you, mr. Chairman. And hopefully three questions i can get in this second round. Im sure there will be followup for the record also. Dr. Clancy, you at the field during in wisconsin on march 30. I joined im a member of the Senate HomelandSecurity Committee that jointly held that with the house Veterans Affairs committee. We heard incredibly powerful testimony from family members of veterans who have lost their lives at that facility or after care there, as well as whistleblowers. Now several months into this investigation cant even at that hearing we are hearing of more tests that were unexplained and we had not heard before. In fact, i sent you another letter today, not based on testimony facility came into being after the hearing and said my husband was printed and i have concerns related to all those that youve been hearing testimony about. And so i just want to stress how important it is to have the investigation be sufficiently expanded to review those deaths and they want your assurances back to the degree we can follow up on everyone that has been reported during the conduct of the investigation that you will follow those, follow the evidence where it leads. You have my full commitment absolutely. I appreciate that spirit is the senator would yield a. Let me just add that i would associate my comments with senator baldwin because a lot of Illinois Veterans which use the tomah facility so we want to make sure we fix the candy store it was called candyland. Candyland yes. On the issue of treatment, proper treatment for pain secretary mcdonald, not only do we have to increase to crack down on inappropriate use of opioids, we have to increase the alternatives to narcotics for Pain Management and veterans are calling for alternatives and complementary medicines and treatments for pain treatment. We are here in the Appropriations Committee want to ask you how the va budget request supports the expansion of complementary and alternative medicine and Wellness Programs that would help veterans deal with acute and chronic pain. As we look at the opioid use which is in the dr. Clancy said we truck quite closely, its moving down. And the reason its moving down is i think we are the largest user of alternative approaches in the country. Weve had tremendous success with acupuncture with yoga with electronic stimulation, and we want to continue that. Anything we can do to provide a different approach than opioid use we want to do. And as ive been touring all of our facilities, i think i visited about 125 so far, im always inspired by those people who are teaching yoga. In one location i was not too long ago there was an art instructor that was helping use art as a way to allow people to become themselves again without opioid use. Equine therapy can we now use equine therapy in places like new bedford, massachusetts. Is a been proven to be successful. So many database way we can improve sex to sex the program we want to. We are doing a lot of research in this area trying to get to understand which veterans and what characteristics to predict a better response to alternatives for narcotics because that is very very critical. I think its back to the notion of informed conversation between a clinician at a veteran, famine and so forth. Great. One final question. We were just talking about the Health Workforce the va. And one of the things that i certainly observe in rural medicine, for example, is if for example is if you see for training there, perhaps if you were born and raised in a rural environment you are likely to make a commitment in your career to remaining there. I think the same is very much true with regard to the va. In the va reform law that was passed last year i authored a provision that was ultimately included that would increase by 1500 over five years the number of gme residency positions. And its my understanding that in his first year of implementation, 204 new resident physicians were added. I would like briefly for you to give me a status update on the programs implementation. Senator, first, thank you for the additional residency slots because i think thats something that will keep paying dividends in terms of capacity. We didnt actually think that we could start residency positions until a year from this july because of the slow ramp up. However, what we did was to go to our existing partners and ask do you have additional spaces and thats when we got the 204 slots. We dont know what the uptake has been. So, for example, every year for the National Match where medical students, its kind of like the dating game right, primary care slots into go unused and so forth so we can get you a report on the 204. Match day with just a few weeks ago. One the other areas to get back to your point about roe care that we are working on is trying to figure out how do we work with facilities and communities that would desperately like to do what you just described but may not have the infrastructure. How do we do that to make sure we could get them the faculty support that they need to the residence who are trying to get a proper education and so forth. Its a very exciting opportunity, so thank you for that. We are also pursuing osteopathic doctors osteopathic doctors tend to be more famine or primar