to provide the committee further assistance. thank you very much. >> at after new chairman mccain, chairman graham, ranking member killer brand and members of the personnel subcommittee. it is a privilege to appear before you today at this initial hearing on defense health care reform and i hope my participation in today's hearing will be of assistance to you in the defense department as you seek to ensure the military health system is strength in and is able to provide optimal support to those who wear the cloth of this nation, their families and those who are in the retirement benefit due to their careers service. i believe i'm a framework for reform is to begin with an assessment of what is working and not working. but the environmental conditions are like me to look like in the future, including the go to work capabilities and needs than what approach will likely ensure success in the future. for my nearly 20 years a privilege service at the site of dod and now va, this worm and up until questions exploration. first, does dod have the optimal footprint and most effective and efficient management structure and tools and system to deliver underneath. and is the investment in the direct care system be enough demise? there's a great deal of expense in the physical footprint, the equipment that has to be purchased and kept current and personnel required to effectively staff the footprint. .. not easy streamlining the number of players and consolidating functions will also make the organization more agile and fiscally efficient. secondly, the benefit available to the population makes sense and is priced properly. the individual could testifies before me spoke eloquently of one component part that ought to be considered. as we all know the tricare benefit has evolved greatly in the last 20 years. having said that, when challenge that remains constant is what to do with the pricing structure which was previously addressed to. i believe part of that needs to including taxing and one of the challenges of programs that are developed is that we fail to index them. a simple actuarially based and automatic triggered index would be worthy of consideration. third, access to care easy? what is the optimal approach to providing direct care system with needed elasticity to ensure access to quality providers is available to meet the needs the direct system cannot meet its self. my understanding is electronic authorization system that allows workflow to efficiently and effectively move between the direct system and the tricare contractors and providers still does not exist. i would say that needs to be remedied. it needs to be grounded in processes that are effected and efficient to include supporting how to make sure they work effectively and accurately. leslie i would say the networks built by those that support the dod's contractors need to be constructed to match the need that exists for care in the community, one size does not fit all. in order to optimize the dod budget those networks should be priced at market rate. fourth, i we optimally promoting health and effectively and efficiently supporting those whose unmanaged health individuals are bad for the individual and avoiding the preventable expense for the taxpayer? promoting health starts with effectively supporting the patient which my colleagues have addressed previously. if done right, it also results in cost avoidance so the two go hand-in-hand with a segment thating the population and focusing in on those who benefit most from assistants in management of their conditions is just smart. annually reviewing the analysis of the population's health is critical to doing this right. developing and deploying an integrated approach to disease management for that specific profile of conditions is also critical, something we tried in tricare when i was doing and we failed to focus in on the right spaces where opportunity exists. you want the treatment to be coordinated and well-managed regardless of where the care is delivered whether it is in the direct system or in the community. there should then be development of a customized treatment plan for the individual patient and the modification of the design of the tricare program to provide a series of incentives and disincentives for compliance with that treatment plan. lastly, a provider payment models that appropriately reward provided for equality outcomes and reduce overall spending need to be adopted as they are the key partner in delivering care. i would suggest doing pilots to continue to test this by deploying it effectively and quickly is important. i would like to draw senator gillibrand's attention, one of the next panel's participants, that is that the site of the first lady of the marine corps, a special educator, we had the privilege, the navy surgeon general, 2 prototype how to put a special needs program together to serve the families at camp pendleton and i believe that worked extremely effectively so there are clues from awhile ago and probably clues from current pilots that could be rolled up and made available as you ♪ the final policy bleaching closing i want to thank you for the invitation to appear before you today. was an honor and privilege for my colleagues and i and our nonprofit owners to be of service to the beneficiaries of the military health system at the site of ladies and gentlemen who wear the cloth of the nation. that is work we will not return to because we have the awesome privilege now of leaning forward in the current furnace and that is where we will stay focused until our job is done. my testimony has totally been helpful to you as you contemplate the way ahead as it relates to continuing to refine the military health system and the important tricare benefit. i look forward to answering any questions you might have, thank you. >> members of the committee is a privilege to participate in this panel. these, should not be interpreted as reflecting -- it is a dedicated force trying to provide beneficiary's, high-quality benefit and maintain readiness to find life-saving care on the battlefield. his community work within a military health system that fails to encourage these outcomes and at times hinders their ability to succeed. i commend congress for addressing challenges. imac three primary points in my written testimony which i will summarize briefly. tricare reform is not just raising beneficiary cost shares. and fix the program that is out of step with current trends, not simply raising costs of retirees to save money, it is about replacing a system of five year winner-take-all largely passed through largely fee for service contract with modernized system that provides, improve quality of the benefit for entire families and retirees and taxpayer money. second tricare reform is an opportunity to bring increased focus on readiness to the missouri health system in particular how to retain the capability built during a wars with the compensation commission reported, quote, research reveals long history of medical mccrery british military community and refocusing its capabilities after concentrating during peacetime and beneficiary health care. before the wars iraq and afghanistan, since most military treatment facilities provide health care to active-duty personnel and beneficiaries, military medical personnel cannot maintain combat trauma skills in peacetime working these facilities. there are a lot of improvements made during the war, military physicians are still reporting, quote, to date the service the physician was referring to it has less than a dozen specialists and the same number of trauma surgeons on active duty. that service has the same number of radiation oncologist and three times the number of pediatric psychiatrist in the force. this is largely because medical specialty allocations, beneficiaries refocusing on wartime needs to populate the institutions for the critical mass of hospital and trauma specialists and drive further advances in battlefield care during peacetime. this focus on beneficiary care mission brings me to my third point. tricare reform is an opportunity to reform the entire military health system. the complex and tweeting set of missions, delivery systems, benefits and funding streams involved duplicative management layers and fails to incentivize unity of effort on the key systemwide outcomes of readiness, high-quality benefit, and cost control. a prime example of this, the military hospital network. and outpatient clinics, the purpose of having that dod run hospital system with clinical skill maintenance platforms for the operationally required medical force. a to d. a. workload and operations of these hospitals exclusively focused on beneficiary health care. as an example i show in my written statement out given the inpatient workload is from the deployed in patient work load. this puts military hospital commanders in an impossible situation. it creates a climate of confusion that affects everyone from staffing decisions to major investment decisionmaking it the military hospitals are key driver of excess costs of health care costs. many of these incentive challenges are driven by a lack of transparency and funding. the service leadership, secretary of defense and congress would not identify what was spent on beneficiary care and readiness, reducing the effectiveness of resource allocation decisionmaking an reducing accountability. i offer suggestions on reform options for each of these challenges in my written testimony and i will elaborate on them in the question and answer period. i would like to close by commending you for taking on these important complex issues and including me in this conversation. >> i will lead this off and members ask questions and i thank my colleagues for attending. the battlefield medical care provided in the last 14 years has produced outcomes historic in terms of warfare. does anybody disagree with that? the answer is you all agree, not your head. let's make sure we don't break the one thing that is working. john whitley said military hospitals are skewed toward family care and not battlefield medicine readiness. how do you explain in light of my first statement? >> is a very sensitive issue. you, said the survival rates on the battlefield have reached unprecedented heights and that is true and that is a great testament to everybody involved in that situation. what i would caution is using that as major clinical readiness, prior to deployment at the start of the wars in 2002, and 2003. the overall survival rate is contributed by many things. we organize the battlefield differently, moved patients differently, and the providing medical care downrange. that measure is the cumulative effect of all those things. what we are asking here when we talk about military hospitals, readiness of the medical force, we have to get down to more specific measures that get at the question of -- >> if you are in uniform, doctor or nurse, you could be deployed, tricare network physicians are not going to be deployed. i want to make sure in trying to fix a system in need of repair that we don't destroy the one thing that works very well. i will look at your reform measures and make short what we do in the military hospital systems enhance battlefield medicine. if you need that footprint even though it might that be the most efficient way to deliver health care, these doctors and nurses will do something no one else will do, go to the battlefield themselves and practice in an environment where they can be shot at. let's not miss that boat. mark fendrick, forrest faison, when you look at tricare for families, active-duty members, how antiquated would you say it is? >> difficult question. i have seen aspects that i think -- >> what grade would you give the overall? >> on an antiquated basis and give it a b. >> so we are starting with a d. >> i say it be plus actually. >> david mcintyre? >> i would say be-in terms of keeping up with where we need to be. >> i will be the odd man out and give the a c at best. >> what is the 30-second answer cost to get us to a? >> military health system needs to do a better job measuring its actual performance and trying to compare its self to internal and external benchmarks and work continuously to improve that care. >> i would pay providers more for providing services that make military members healthier. there's strong evidence based to back that up and make it easy for members to do that. >> i would ensure that providers getting paid for their performance, and make the patient impart responsible for their care from an incentive and disincentive perspective. third i would index the benefits so that it properly keeps pace with inflation and forth, i would focus on the question of alignment of providers in the direct care system with providers that are down down. in terms of requirements but also in terms of what their focus is. >> i would focus with respect to the tricare contracts i would focus on increasing greater competition, having annual contract with multiple -- i would focus on contract being risk bearing and increase its ability to the contractor to manage the care. >> could you provide in a three or four page report to the committee how you go see to a and c plus to a? be specific. >> thank you all for being here. our country has a shortage of mental health providers resulting in many patients receiving mental health care from their primary provider. what do you see as the solution to this problem? how do you ensure mental health providers in the network had experienced unique needs at with service members including military children and last does tricare require this type of experience? >> we no longer do the work in tricare which is partly why i am here because i don't have a conflict in that regard. it was mapped to the needs of the population, both those that are close to a military installation but also those observed in the garden research. what we currently do is relevant to that topic and that is we are doing exactly the same thing and we're looking at the sid code where people live and what the direct care system has in the way of footprint which i believe is applicable to the dod and we are going back to something we did at the start of the wars and that is to train the mental health providers and primary care providers in how do you recognize where a threat is for your patient from a mental health perspective? how do you be relevant and where do you turn people to in distress? >> if we are changing from how much we spend to how much we spend we would see a serious investment in infrastructure, to do evidence based services. >> what infrastructure changes would you make? >> the problem is most medical services that are most profitable would have a lot of help for the money is spent and as long as you continue to allow fee-for-service payment system they will go to the services that produced lots of revenue that have never been measured, points made by folks to the right and the left of me. if we again get to this point and say i will pay a lot of money for a military healthcare, but insist that it goes to services and providers for things that are actually needed whether it be mental health, bogey at abuse or other things that are away from the standard cardiology and orthopedic surgery and other things that are needed but tend to be overused in the system. you have enough money dare, it discouraged to make the shifts that are going upstream end you may not want that to happen. >> i would add that integrating mental health care into primary care is important. i don't mean mental health care is provided solely by primary care physicians that breaking down the barriers and sharing information about patients with behavioral health problems there are great privacy concerns about behavioral health but when primary-care physicians and others not treating the same patients are not aware of those issues we cannot bring to bear all of the power of the multi specialty power we have in front of us to the care of mental health patients. >> i have nothing to add. >> major concern is the care of service members special needs dependence, military families moved frequently and that means moving to different levels of service provisions, we have private sector experience, how do we ensure continuity of care for special needs are met when secret service members may be moved and how does tricare handle provisions of the specialized service? >> i think that is a fundamental question and the thing that's forrest faison and myself learned at the time through the lens of the marine corps was you need to understand what the needs are and pay attention to them and meet them in their midst and you need to prepare and plan for their change geographically so as they move from place to place your thinking of them not only moving forward but receiving them on the underside. the same thing applies to those that are injured and those that have mental-health needs. as they move within the system of the military and also between military and the va. last thing i would say if i can go back for a second for the mental health issue raised previously, very few providers in this country are trained in evidence based therapies and we have a network of 25,000 mental health providers now built across 28 states. we are in the process of looking at that issue market by market. we are doing something to get there as well as those that serve in the federal space. the bottom line is it is possible to go through and do that training and expertise of it exists in the va spaces. bringing those networks to the table to narrow in on the populations the need services, how many there are, make the investments that ensure they are trained and we are testing that in the chairman's home town of phoenix, ariz. starting this weekend. >> i am very interested in your recommendations. one of them, management layers should be reduced. talking about one service? >> many options to do that, one option is consolidating the military health agency, another would be a secret service, many options to get there. >> do me a favor and send that to me in writing. >> i would be happy to. >> in t fs should be professionally managed. is that what you are saying? >> the option is over the table. i don't know -- >> would you recommend a private program where we contract out for a non-military associated association to conduct some of these functions. >> this is an option to consider. their are outpatient clinics in the direct care system. >> how is that working? >> my understanding is the beneficiary, the next panel can talk about their experiences from a management perspective. >> this is what we are talking about. >> the best way to motivate people to improve is to make sure they are not the only game in town. >> how do you do that? same way? pilot program? >> you take specific markets and allow beneficiaries to choose between venues to receive their care and it will be interesting to see where the beneficiaries choose to go, and costing those markets. >> what would be the option? at you say there are no options they would pursue. what would those options be? >> civilian provision of the health care center. >> private hospital or private provider or private insurer? >> they go to their primary care would be primary-care practice. >> in t fs can't succeed should be downsized, has there ever been an empty have downsized or closed? >> the director is half the size as it was. >> it is about half the size. and we are close to 100 probably 20 years ago, senator. folks in the second panel will have the numbers better than i would. >> to some degree what you are talking about overall is competition. >> yes, senator. >> manifested itself in different ways to be more explicit. and tool for managing and outcomes and cost control. >> i wonder if we have a look at some of these recommendations for pilot programs as a beginning. >> finally, do you think we should have one service, or should we maintain three four separate ones? >> i am willing to take a stand on competition. >> do we have medical staff? >> yes, we do. >> i thank you, mr. chairman. >> thank you all for being here. the testimony, both written and delivered before the committee talk about value based insurance design, something i got involved with in north carolina, a matter of public policy, and i want to talk a little bit more about that and how you think state health plans that have done it to the extent that you can and any member of the panel can benefit. may not be related, and the briefing materials, one thing that jumps out at me that i would be interested in any panelist's opinions on this, the medical health system, her 1,000, 61.7 for enrollees in the medical health plans and 36. there is a really big gap. what narrows that gap or are there legitimate reasons why the gap is so great? >> i will take the first half of the question, my fellow panelists can chime in about the solution in this important hospitalization problem. and the financial barista high-value services and providers, and the state of south carolina the medicaid program reduced cost sharing for high-value drugs for the most vulnerable population there. and the empire state has highlighted the new innovation plant, very important role, state innovation, $100 million grant model. and the main state innovation plan, it is an important part of the private-sector main business coalition. you pointed out, and these plans are offered to state employees in 13 states in north carolina. and one voluntary plan was taken up by over 90% of state employees and after two years we saw a marked increase in healthy behaviors preventing screenings, much clearly delineated consumer satisfaction. and we see emergency room visits and specialty visits decline. and we have information on hospitalizations because they occur in a compressed portion of the population. those are often people focused more often on why we recipes for bipartisan bicameral political support for demonstration medicare advantage. and steadying regularly programs that lead to the reduction in readmission this. but i think over the long term we will see modest impacts on the our visits and hospitalization, and you are able to tell your constituents and taxpayers that the american health care is moving not to what made people money but are finally moving in a very systematic way to what makes them healthier. >> i would agree that providing incentives in value based incentives is the right thing to be doing. and the interesting thing about tricare and the dod system is not all the care is provided in one domain and that makes it uniquely challenging. the chairman of the committee is not here at this juncture. but the air force went through a massive footprint process back in the beginning of tricare, and did an amazing job of footprinting its installations. i think some focus on the question of the size and structure ought to look like and what do you have to supplement it with to give elasticity from a provider perspective? what types of providers and system is do you want? if you have an integrated delivery system, how do you put that in? some delivery systems, the models need to take care of the entire patient and not just part of the patient's needs. what i would also offer is some of the prototypes of design that have been done over the last 20 years are worthy of exploration and assessment and there may be some new prototypes the need to be done, but there's a lot that can be tested. and figuring out what its application might look like to end up making changes would be smart. i am particularly intrigued with the notion that you take the defense department for a population that has indeed for and you take the va for population it has need for and in the same community you are melding that together. there is a series of prototypes that are in place for 20 years now that did that in different ways, tweet different markets. the chicago approach to read it together and how the bring the third leg to the stool? you can go to gerald's champion in mexico. when senator they medici was here there was a prototype, took a small community hospital in an air force location and took the chairman and put them in that hospital. took the va folks in hospital, delivering services in that environment doing operations there. the private sector was the third leg of the school, the only prototype that was ever done like that but the incentives in communities that are smaller wear on their own they should not be doing everything for themselves, offers a lot of interesting assessments and you might find there is a lot of fodder already there to step back and say how do we do this right? what are we missing in models or do we have most of them already tested and how do we footprint forward with the right kind of requirements of folks before they start doing design and construction? >> thank you. that was a great model. i am out of time but a part of what i am going to lead to is reforming health care system like kaiser permanente, that is a model we have to look at and develop as chairman mccain said through a pilots. serving on the veterans committee is an important topic and a way to target a lot of the needs in certain areas of the country. the only comment i want to make may be something i bring up in the next panel. there is one more detail i want to get on the record and i think this is of the gillibrand might have look but the treatment. in my discussion with panelists outside this committee. if we could be more methodical we are making a mistake cutting treatment options below the national average and producing a bad outcome for something that has been proven to be highly effective and highly beneficial to those who take advantage of the treatment. thank you. >> that was excellent. next panel please, thank you for participating. that was very helpful. [background sounds] [background sounds] [background sound] [background sounds] [background sounds] >> thank you. we will start before we went to another subcommittee hearing. i turn it over to senator gillibrand and i will be back as quickly as i can. let's get started. >> chairman graham, ranking member gillibrand, members of the committee, thank you for placing the issue of military health reform high on your agenda for 2016. the military health system takes great pride in its performance in combat mission over the last 14 years. 95% survival rate for those wounded in battle. our ability to prevent disease through exceptional primary-care and preventive medicine produce equally historic outcomes in reduction of disease and non battle injuries. the challenges we face in medicine and national security continue to evolve and require new approaches to be prepared for the future. we have undertaken a number of initiatives to strengthen military health system in all facets of its responsibilities and have been organized around six principal lines of effort which we have spoken about in previous testimony. i therefore want to encourage last year's military compensation and retirement modernization commission reviewed and supported many initiatives we already set in motion in the department. let me briefly describe these efforts. first we have modernized our management systems with an enterprise focused, established defense health agencies vice admiral bono leads and providing, and business processes in business and support of military departments and combat commanders and approach greater operational the efficiency for joint solutions to customers. we identify multi service market and develop five business plans to promote common solutions and optimize use of military treatment facilities while providing required care to beneficiaries in the purchase care sector. in addition we acquired and are preparing to deploy a new electronic health record using commercial off-the-shelf products. together with surgeons general and vice admiral bono we have established an enterprise wide-board to perform readiness, access to care, quality, and safety, and costs. the defense health agency achieve the milestone of full operating capability on one october 2015 ended its first treaty years saved $750 million. we are defining and delivering medical capabilities and manpower needed in the 21st century with services the department has embarked upon, the federal processes define essential medical capabilities and metrics to monitor readiness. third as a result of modernization study we have analyzed infrastructure needs and several military treatment facilities as well as made adjustments to move, skilled medical personnel to markets to recapture care, they can maintain their skills and reduce overall costs. the fourth line of the effort is the main focus of today's discussion. that is our plan for reforming tricare. we are appreciative of the input from service organizations, to support tricare. the tricare benefit was that number one health plan in the country for a customer experience by 2015. boeing in all small part the comprehensive coverage and low-cost job beneficiaries and we jockeyed for that position, and loud and clear for beneficiaries, access to care and primary and specialty care needs attention particularly in the empty s. we implemented a number of access improvements to open up more appointments or resolve appointment issues on the first call, improving access to after our care particularly for child care, when did that is through evening, weekend clinics, ability to e-mail providers questions through secure messaging, the availability of nurse advice line, with the pointing system, streamlining the referral process implementing urgent care, demonstration programs congress requested. our contract will be awarded in 2016 and includes provisions that further improve the experience of care for the beneficiaries. the proposal provides shoelace and incorporates feedback from stakeholder groups. the fifth line of everett expand strategic partnerships with civilian health organizations to enhance the ability to meet and exceed quality, safety and satisfaction. partnerships with organizations such as american college of surgeons and health care improvement, and to sustain trauma system, improve clinical quality, achieve our goals at high reliability organization. finally the sixth line of beverages focus on global health engagement where the department is deeply engaged in national security threat posed by infectious disease and building bridges through health care around the world. we contributed to surveillance, diagnosis and treatment strategies to combat well known outbreaks to include ebola and now zika and preventing other outbreaks from occurring. we entered 2016 confident that reforms in the military health system in the health benefit can be further strengthened through a combination of legislative and operational reforms. i am grateful for the opportunity to be here today and look forward to your questions. >> chairman graham, ranking member gillibrand and members of the subcommittee, thank you for the opportunity to appear here today. i am pleased to represent the defense health agency and explain how we are contributing to the modernization of the military health system. in november i was honored to become the defense health agency's second director. only a month earlier, the agency had reached full operating capability. mark ediger two years of collaborative work with army, navy, air force medical leaders and the joint chiefs of staff that established the concept of operations for many functions of the agency. our responsibilities center and supporting military department and a combat commanders and execution of the mission. the defense held agency was created in recognition that most health care delivery is common across army, navy and air force. what we need, what we buy, best practice entails in the clinical and administrative environment, the defense held agency helps bring together, and support functions into a new enterprise focused organizational structure. we are able to help jonathan woodson and surgeons general c. and manage in a more unified way. one of the principal ways we deliver the support is through the operation of shared services. critical enterprise activities include tricare, pharmacy operation, health information technology, medical logistics, medical r&d, education and training, health facilities, contracting and budget resources management. in addition to the ten shared services that have been implemented the d j.j. has brought in joint activities that have previously been distributed to the services that acted as executive agencies. these include the armed forces health surveillance center, the armed forces medical examiner system, dod medical examination review board, defense center of excellence for psychological health and traumatic brain injury, the national museum of health and medicine. the da j offer's value to more services, we serve as a single point of contract for many interagency and external industry matters. simplifying up process for our partners and outside colleagues to work with the department of defense in support of a number of in. such as research, global help engagement, adoption of emerging technologies, health care interoperability and more. the existence of the daj streamlined the defense agency, defense information and other field agencies. external to the department, there's a single point of contact for operational matters within the va, a number of agencies within hhs which includes centers for medicare and medicaid services, the food and drug administration, centers for disease control and prevention, public health, and we successfully collaborated with the justice department on the prosecution of health care fraud cases. most recently with highly suspect activities around compound medications. we work with treasury, state and a number of critical functions that directly support our health care mission. i would like to focus on one shared service in part to get the cooperation of tricare, military health plan, tricare modernization as part of modernization plans-jonathan woodson just outlined in the number of initiatives in 2016. leaders this year we will award the next round of contracts known as pete 2017 which is when health care will be operational under the new contracts. we are simplifying contracts, reducing management over hitting government and contractor headquarters moving from three regions to two regions. we are expanding the means by which we manage quality of our network to ensure they meet expectations for quality and safety that we expect our beneficiaries whether the direct system or in private sector network. we also will introduce innovative models for value based purchasing in the coming year by staff in close collaboration with services also crafting the contract amendments to permit tricare and released to users and care centers without reauthorization. and our analytics team provides department's civilian, military and medical leadership at headquarters and field level, the ability to assess enterprise wide performance with the military health system using the agreed upon joint measures for readiness, health, quality, safety, satisfaction and time. d h a is an integrated part of the health system. we are proud to contribute to the modernization of the system, join collaborative solutions and irresponsible management approach. i am honored to represent the men and women of the defense health agency and i >> distinguished members of the subcommittee, thank you for this opportunity to provide perspective on defense health care reform. it is an honor to serve as army surgeon general and commanding general of the u.s. army medical command. since 1775 army medicine has supported the nation and the army whenever and wherever needed. however today i would like to focus on our more recent history. for the past 14 years we have supported an all volunteer force, engage across the globe in supporting the joint campaign fighting in iraq and afghanistan. and responding to national disasters and other contingencies like the u.s. government response to the ebola outbreak in west africa. we have accomplished this while continuing to attract, educate and train the next generation of army medicine. we are collecting what we have learned over the past 14 years and in ensuring we are using these lessons to inform our daily efforts and how we prepare for the future. our readiness when needed is my number one priority. assuring our readiness are madison must maintain medical capabilities that are ready to deploy and support our war fighters. during the past 14 years of combat operations we have achieved survivability rate as you heard of 92%, the highest in the history of warfare. despite the changing tactics of adversaries and increasing severity of battled injuries. this gives knowledge and practices that achieve the survivability rate. these advances in combat casualty care resulted in integrated health services expanding continuous care from prevention to treatment of illness and injury and rehabilitation in both the garrison and operational environment. we cannot however focus exclusively on sustainment of combat trauma, surgery and burn capabilities. the army must be agile and adaptable and therefore maintain a broad range of mental capabilities to support the full range of military requirements. we see medical centers, hospitals and clinics in health and readiness platforms. they ensure we maintain trained and ready medical personnel by exposing them to diverse and broad range of patients with a wide variety of illnesses and injuries. medical center's serve as platforms for army graduate medical education programs. these programs are the primary means for transferring knowledge from this generation of military providers to the next. we focus on the readiness issue we must also ensure we provide soldiers, families and retired population with access to high-quality health care that meets their needs and encourages health. improving access to care is a priority for army medicine and i have direct action to rapidly improve access to care. first we enable beneficiaries to book an appointment six months in advance. we already i did that several installations. we will increase the number of available appointments by increasing time our providers are available to see patients and reducing the number of appointments and working on the no show rate which leads a large number of appointments and utilized. additionally we are opening three new community-based medical homes and will evaluate where after hours or urgent care clinics are necessary. as part of the health service enterprise we will continue to expand our health program, currently conducting pilot to treat low acuity patients in the emergency department at fort campbell is one example. also expanding remote health monitoring programs and expanding health to home. i would like to thank jonathan woodson for signing the policy to expand that facility to initiatives. it will have long-term sustainability of tricare but reforms must i increase the financial burden on active duty soldiers for active duty family members it, minimize any impact to our retired population. before shedding courage beneficiary use of direct care system to ensure medical military skills are maintained, should encourage healthy behavior is as you heard colleagues mentioned previously. but reforms must not be great combat tested system or readiness in an environment where we must remain rotational the focus and surge ready as the next deployment could be tomorrow. the army's fundamental task is like no other. it is to win in the unforgiving crucible of ground combat. on the medicine does not fight wars, we are however a critical enable it to ensure the army and cheese this end. our nation's mothers and fathers know that when sons or daughters are ill or injured we are there. we are ready and this gives them the confidence to send them into harm's way if called. this is a sacred trust and our readiness to support war fighters can never, will never be in doubt. i want to thank you for your continued support to our soldiers and military medicine and i look forward to your questions, thank you. >> chairman of graham, ranking member gillibrand and distinguished members of the committee, thank you for the opportunity to come before you to discuss the future of the military health system. we fully support the committee's work to enhance the focus on value and delivery of the health benefit to those we serve consisting of sustained good health, streamlined patient experience, radius of the force we support and the readiness of our medical force. strong health systems must continuously improved. changes to the air force performance management process implemented in 2015 is part of the coordinated action plan following military health system review. producing continuous improvements in safety, quality and timeliness of care. recent dividend includes the joint commission recognition of our hospital angeles-based richardson for outstanding performance on key quality measures. the key for medical center's top 10% ranking among all u.s. hospitals participating in measures of patient perspective. and favorable systemwide performance against national benchmarks, diabetes, management and child-care. we know performance as a health system is in trouble to our readiness and we remain committed continual improvement. today we have 683 medical errant deployed around the world providing medical support to contingency operations including the trauma team at craig joined the hospital in afghanistan, mobile surgical teams in various sites and medically evacuation teams with critical care capability. our success in support of the ploy operations is linked to the care we provide in our hospitals, clinics and partner institutions. the bedrock of our readiness is the military hospital. of the 76 air force military treatment facilities, only 13 to they are hospitals. i would add 40 years ago in 1986, we had 73 hospitals and over the past 30 years the air force has closed and converted 60 hospitals. our capability to meet combat requirements with the play is unable medical teams hinges primarily on our eight largest hospitals. the broad scope of care we provide military members, their families and veterans is key to that. a number of agreements under which we provide specialty care to veterans as we consider changes to the military health care system we believe it is important to facilitate retiree access to specialty care in military hospitals and provide tools enabling more agreements with the va and other federal health system this. to ensure our readiness we have evolve to a model in which air force surgeons and critical care specialists devote a portion of their time to provision of care and are institutions such as va medical centers and level 1 trauma centers where more complex care and trauma are prevalent. i would offer as an example the medical group that knowledge air force base in las vegas where surgeons on staff, orthopedic surgeons and general surgeons do a significant portion of their cases in the of va medical center in las vegas but also at the university medical center in downtown las vegas which is the only level 1 trauma center for las vegas. this provides a needed balance of complex cases for proficient deployable commission. and additional key point pertains to primary care support for active duty families. experience has shown primary medical support to active duty families from military treatment facilities enhance commander at efforts to support families and distress and strength and resilience of families. changes are strongly recommending care, in facilities. i think the committee for steadfast support and dedication to the welfare of the airmen, soldiers, sailors, marines, their families and our veterans. >> distinguished members of the committee is my honor to represent the men and women of navy medicine, 63,000 dedicated professionals who every day on a trust and caring for those who sacrificed to defend our freedom. we are grateful for your strong and unwavering support of service members and families. as you considered changes to the military health system i thank you for that but i would like to highlight important considerations i believe are central to any discussions. military readiness, combat support of our mission. it protect, promote 10 restores the health of sailors and marines are on the world at home and deflate. we are equally privileged to care for their families. inert increasingly complex world as navy and marine corps, navy medicine stand there as well to protect and care for them. as an agile deployable medical force this sets us apart from civilian health care. no civilian health care company in the world routinely leave their families and homes on a moment that notice to go into harm's way to care for those in need. no health care company in the world daily puts their lives on the line in battle to defend and care for their patients as young hospital corpsman second class was privileged to be awarded the silver star two weeks ago did without thinking. no company in the world experiences the staff deployment and turn over we routinely experience and still deliver world-class care. finally, no health care company in the world is daily and singularly focused on combat readiness of its staff and the proof is on the battlefield. highest combat survival in recorded history. wounded warriors are alive today who any previous conflict would have died from their injuries. they are the testament to the effectiveness of the military health system because every one of them from point of injury on the battlefield to advance treatment medical centers receive their care from men and women who got their training, experience and preparation in the military treatment facilities. those facilities are the foundation of battlefield survival and in my opinion as a former commander of the ploy expeditionary combat medical facility a robust military health system is critical to future battlefields survival. unparalleled combat survival in the nation's longest conflict is proof that robust military system that serves as training and search platforms for battlefield providers from korman to physician is essential to combat survival and agility in rapidly supporting deplane operational forces. the three facts are not in dispute. we have the highest combat survival in recorded history. many wounded warriors alive today would have otherwise died of their injuries he in any previous conflict. every wounded warrior receive their care from injury on the battlefield to recovery in medical centers exclusively by men and women who receive their training, clinical experience and preparation in one of our military treatment facilities this is a system that works and has proven itself time and again, thousands of men and women alive today. is also a system that is not perfect and i appreciate your attention to this much needed area of reform and improvement. the services are working hard to improve access, continuity, convenience and satisfaction with care and benefit that we deliver in these times. we have made important strides in each of these areas and increasing enrollment, network recapture, staffing realignment and other efforts to ensure we provide clinical experience our staff needs to provide skills, competency and alternately combat survival in the next conflict ended is more than trauma. 70% of the evacuation and the recent conflict were not trauma related. every person on the team, every person wearing the uniform in the navy today matched and operational platform, assigned to an operational platform. we do not have people in uniform for peacetime care. all of them have necessary roles and responsibilities in the next conflict. more needs to be done in none of us understand the required health care services. and necessary reforms would improve the patient's experience, and most importantly their help. we must do so without putting at risk the very system which has yielded some unprecedented survival. we need your help for your tireless support, i think you for helping us to ensure that those sailors and marines that stand watch in the future will have the same or better survival than today's wounded warriors have had. in our hands this sacred trust to do all in our power to return safely america's sons and daughters with sacrifice to defend our freedom. i think you for helping us to honor that trust today and tomorrow. >> i am grateful for your service and i appreciate this discussion. i would like to start with jonathan woodson. we are interested in comprehensive autism care. i am cleanest please be offensive care demonstration in 2013, i am interested in seeing the outcome. i am concerned here is that dha plans to lower rates for autism. i am most concerned the providers will no longer be able to accept tricare because the reimbursement rates are too low. the mpeg changing reimbursement rates will have on therapy and what steps have you taken to insure access to the services will not be adversely affected to make changes in reimbursement rates and why not waiting till the demonstration program is complete sayre results ao resul skewed by >> reporter:? >> we are committed to special needs children. we did an internal study on rate because there were no establish national rates and part of the statutes require as for medicare rate so we set an amount and studied it for a few years, did an internal review and we were about to make rate changes and we heard from stakeholder groups including autism speaks and others convene repetitive conferences to engage them and commission two outside studies confirm they were overpaying and would be happy to share the details of these studies with you. finally, to ensure they won't negatively impact services we reviewed network adequacy on a monthly basis, certainly very frequently so we are monitoring this situation very closely. should we find in fact in any locality it has been adversely affected, we make rapid changes. final point in regards to is this is we put in a safety valve and we are not going to reduce rates right away completely. it is a step wise progression over a number of years, they cannot lose providers. >> the methodology, they are reflective of the cost and so to request follow-up information on that, and further consideration, i think is inadequate and reason autism speaks so forcefully against rate changes because they are the experts on treating children with autism so i think your study is misleading in its outcome so i will follow up with specific questions but i would like this to be addressed because i am very concerned that there will be negative consequences for patients. my second question is about innovation and different ideas about how to innovate health care for our service members. in upstate new york i was in a press with their approach to health care. they have a clinic for basic primary care and service to members of their families for members, and members and families go off base for specialty care. clinics and provide is in the community, have an excellent understanding of needs of the planned women in uniform and their families so this is a long lines of questions that senator mccain asked in the last panel so has dha looked at the model for providing health care and how to leverage community health care options serving the military community? >> i will share with you what we have in san diego, one of every five residents is eligible for military health care, that is 250,000 people. of those, 662 are high utilize theirs, folks that use anywhere from 15 to 30 times as much health care is anyone else in the county. we have public health to manage them as a community-based efforts. these are folks the car will break down and they call 911 to get a ride to the e are to get medication, care will be fragmented in a variety of urgent care centers so if i part with a county health for county services as well as military provider services of medical home of roche, a community based format, we improve their health, cut their health care costs in the first year for 250 of them by $4 million in the second year by $12 million and dramatically cut by 60% our hospitalizations the that is one issue we are in the process of exporting across navy medicine. >> regarding the innovation of health care, a phenomenal model for that area but it might not fit in all the demographic areas and the sizes vary from location to location and may not be reproducible but there are additional things we are doing in leonardwood, missouri, where they have a virtual i see you've set up where they have been derangement with and i see you in the state of arkansas to help them with that. and with different types of partnerships in order to achieve some of the same ends but i agree the fort from community, the model that they have works very well. >> i mentioned in my statement the air force has 13 hospitals, that is below our operational requirements for deployable medical teams and we had to use some innovative concepts in order to meet our operational requirements so we have 2,500 air force medical personnel embedded in other service hospitals and that is one way we're doing this. we have embedded surgical staff in private-sector hospitals in omaha, neb. tampa, fla. phoenix, arizona, oklahoma city and birmingham, alabama and they're providing beneficiary care in those hospitalss. i would say while that model has been successful to some extent i don't think we can go too heavily in that direction because as i said in my statement the military hospital remains the bedrock because it provides readiness to the entire deployable team. the enlisted, the nursing staff, and embedded operations, private sector platform stands to benefit the provider staff but not so much the nursing staff. >> there are other areas we have been doing innovative work and this is in the enhanced multi service market and each of these have this where we have 45% of of resources and 45% of patients where we need care. and with those resources, depending where the demand is for care. other hospitals in the same market where the demand is. and in national capital region we were to looking at the demand for physical therapy services. and coming from referrals and in the imbedded facilities we were able to send physical therapists to those clinics where there's a high referral rate and by doing that we were able to get care closer to the patient and more timely manner and see decreased demand for specialty care down the road so this is something all of the services have with enhanced multi service market. >> thank you very much. >> thank you, mr. chair. rather than go back through what senator gillibrand brought up on the treatment, i would like to join with senator gillibrand and follow up, it has to do with fine. and profoundly important value of the treatment, not only the child received in the treatment but also the quality of life for the active-duty personnel, military personnel and spouses. i want to start with you and ask the surgeons general to chime in because you're making an important point about the unique nature of this health system but i also want to get to military hospitals and clinics, it costs 50% higher than what it would cost of services were purchased in the private sector. can you give me some help in trying to rationalize what the real gap is because there are structural costs based on the unique nature of what you are doing but give me some sort of sense of what you believe may be an unattainable goal or narrowing the gap or is it right and proper? >> absolutely. if you look at our costs, costs break down into two large buckets that the two large buckets are facility costs maintaining embedded facilities. those are important as we get casualties back, the walter reeds of the world and places like that the >> the capacity you may not find in comparable private health care settings. >> absolutely. if you look at the civilian sector they are running the occupancy of 90%, we don't do that because our beds are in reserve for contingency operationss. the others are personal cost. we have in some places more staff in uniform than necessary for peacetime demand but that is because of a personal war requirement. we tried to put those personnel in place is to keep their skills current. we heard from other surgeons general when we can't do that we do service rotation at civilian centers and places like that. >> sorry to cut you off, got a couple questions, but is there a good break course something you can provide us that really gives that to us in an empirical way, if you make decisions, saying we narrowed the gaps that it is no longer her 50% if that is the right number, we understand the trade off in capacity and what you are preparing to deal with but this would be helpful to get back to this committee as we go through and identify opportunities, and opening statements say you are not perfect, and spend the bulk of our time on this committee fixing those rather than going down a path where if we look at the data we may agree it is a structural cost of doing business and the unique nature of your business. >> do you have a comment? >> yes, sir. one thing that is a challenge when you talk about differentiating cost of readiness versus cost of providing care, as i said in my statement the two air inextricably intertwined and there's a lot of work we do that is operationally driven that is critical in nature so if you look at our primary care operations, things like medical evaluation boards, annual preventive health assessments, post deployment health assessments, all these things consumed a significant amount of primary care bandwidth so is very challenging, the cost of providing care to enrollees to our clinics and cleanly cleve and separate the costs of readiness to providing care so that is one of the traditional challenges we always had with answering this sort of question, the two are intertwined very significantly. >> to normalize it so people can understand it so we set priority on things we should improve rather even look at things from a purely numerical basis that on the surface may look like an opportunity to drive improvement and consequences could be the opposite, to work with you and improved. the tricare legislative proposal did not contain any recommended improvements for reserve communities but what is in the offing? what can we expect? >> thank you for that question. that set of proposals really requires additional studies, but there are several courses of action depending on what type of reservists we are talking about. let me give you some examples to crystallize. on the one hand we initiated reserve select to fill a gap in what we thought was medical readiness at the height of the war. the consequences of that, a reservist and family would have to switch insurance program this when they came on active duty so there is the possibility of a larger population including an employer based option which might be reasonable. there is the possibility as the commission talked-about, providing basic allowance for health coverage on active duty and we need to sort that out. and there are some other hybrid options that are out there. the issue with reserve is about not forcing them to change providers when they come on active duty because there are different solutions we need to work out and study a little more. >> thank you, mr. chair. >> thanks, mr. chair. as you may recall, in the 2016 national defense authorization act i advocated for a uniform formulary for improved transition from dod care to the va as a service member's transition out of active service. this measure would pass and we are in implementation stage, the joint formulary is critical to the kind of care and relates to a variety of related issues that may i rise when there is a lack of sufficient transition in prescription drugs and health care. what is the status of the implementation in the joint formulary from d a d perspective? >> there has been much progress in the areas of mental health medication, pain medication and those other critical medications for conditions in which a gap would create problems. to the 96% level, we have a single formulary and i know there is a little more work that needs to be done on that but there has been significant progress on that front. >> on the issue of prescription drug, pain killers and of the lloyd's, is there an ongoing danger in the military as there is in the civilian world, over prescription and overreliance on painkillers? >> there is. something that needs to be addressed not only nationally but in the military health system. what i would say is i think in that regard we are a little bit ahead of the curve and the reason being for a lot of different reasons there has been a lot of focus on the use of pain medications so we have developed more comprehensive strategies in terms of clinical practice guidelines, we have courses that providers must take in terms of pain management. we have invested in research and integration of alternative methods for pain control so this has been part of a comprehensive set of programs i think we could even make available to some civilian health care systems. >> has there been progress there? do you think? >> i think there has been progress, mental health care the more we study and the more we try to refine it and find out about it. if i could break this down to a couple of different issues, often times dealing with mental health is more about delivering mental health care and delivering social services and family support and that is one issue, the other issue about mental health care is we always have this issue about whether or not we have enough providers but what we need is a comprehensive new strategy for how we employ mental health specialistss in a rational way to deliver care. we never will have enough psychiatrists, we will never have enough pediatric psychiatrists but if we utilize them to do screening, we make their time less available for treating complex problems so what we need to do is work on a more rational approach to how we avoid certified mental health counselors, psychologists, psychological nurses, licensed social workers and a continuum of care, and i am not sure we will ever generate enough mental health providers? >> that is a strategy you say has to be developed or is being developed? >> we are working on that. the previous panel talked about the issue of embedding mental health care and primary practices. we have been doing that for years. we have been betting mental health care technicians and practitioners, so we have already rolled out some of that more comprehensive strategy but still we need to raise different types of mental health professionals in a better way to take care of many different problems. >> as you know, active duty members may suffer emotional or mental diseases some of them emanating from traumatic brain injury, some of them are given bad conduct discharges, bad paper, and through a tragic irony deprived of medical care to treat the very injury that causes their discharge under less than honorable conditions and i have sought to have those discharges reviewed and in fact two secretarys of defense beginning with chuck hegel and most recently ashton carter have committed to change the policies of the boards of correction review within each of the services, has your input been sought? because there are medical issues involved in those reviews? >> the short answer is yes. thank you for your advocacy in this arianna and the last two years we have actually reached out to individuals to have been discharged to let them know that their cases will be reviewed but to the last part about your question, there have -- we have given them to these boards so their cases can be accurately reviewed. >> thank you. my time is expired. this is tremendously important and i want to thank all the panel members for your hard work, all of the hard work done by the men and women under your command, thank you for being here today. >> how many casualties have we suffered in iraq and afghanistan? not fatalities but injuries? how many people have been wounded requiring admission to the hospital? anybody know? >> depends on how you calculate those numbers, include disease -- >> in iraq and afghanistan -- >> over 100,000. >> can you imagine military health care system did not have a military hospital? >> no i can't. it is not for everyday activities designed for wartime contingency. >> that is correct. >> most of these beds are empty because during peacetime, they are built to deal with wartime contingencies. >> those beds are not empty. we work closely with managed-care support contractor to get managed care into our facilities. >> what percentage of your bed occupied? >> we try to maintain 80% or higher. >> what about the air force? >> we have a lower bed occupancy than that, we are more in the 50 sometimes up to 70% range. >> it varies. the large in the s 4 brag san antonio have a higher occupancy rate to smaller facilities. those are the ones we are looking at to realign capabilities. >> so here is my point. if we are going to reform something we need to understand we are trying to accomplish. any hospital administrators over military medical facilities would that create a problem? >> military hospitals are like any other military command. >> it is what you would be doing. hospital is a military entity and the military command structure can't be substituted. >> yes, sir. good order discipline carries over to the battlefield and starts in the hospital. >> at the end of the day what would happen if we open up competition to all these military facilities? where would the minister -- speech we will leave this hearing to bring live coverage of the u.s. senate and senators meeting to vote on president obama's nominee to head the food and drug administration lists several lawmakers oppose the confirmation due to the fda's response to a buick addiction. a vote on the nomination is scheduled for 11:00 eastern this morning. live senate coverage c-span2. the president pro tempore: the senate will come to order. the chaplain, dr. barry black, will lead the senate in prayer. the chaplain: let us pray. o god, we would rest in you for you alone can bring order to our world. reveal yourself to our senators, guiding them on the path of peace. may they place behind them disappointed hopes, fruitless labors, and trivial aims as they lean on you for comfort and strength. rebuke their doubts. strengthen the good in them so that nothing may hinder the outflow of your power in their lives. give might to the weak and renew the strength of the strong. we pray in your holy name. amen. the president pro tempore: pleae join me in reciting the pledge f allegiance to our flag. i pledge allegiance to the flag of the united states of america and to the republic for which it stands, one nation under god, indivisible, with liberty and justice for all. mr. mcconnell: mr. president, are we in a quorum call? the president pro tempore: we are not in a quorum call. mr. mcconnell: mr. president, president obama has left the american people to wait many years for a serious plan, one that poses no additional risk to our nation or our armed forces. for instance, in pursuit of his desire to close the secure detention facility down at guantanamo bay. americans have been waiting for seven long years to find out what the serious plan might look like. they're still waitin waiting to. what the president sent to congress yesterday isn't a plan. it's more of a research project, if anything. it does call on congress, however, to act. it turns out we already have. congress has repeatedly, over and over again voted to enact clear bipartisan prohibitions on the very thing the president is again calling for, and that is the transfer of guantanamo bay terrorists into our local communities. we've enacted bipartisan prohibitions in congress with split party control. we've enacted bipartisan prohibitions in congresses with massive overwhelming democratic majorities. just a couple of months ago, members of congress in both parties expressed themselves clearly one more time. not once, but twice, and on an overwhelming bipartisan basis. president obama signed these bipartisan prohibitions into law as well. so let's not pretend there's even the faintest of pretenses for some pen-and-phone gambit here. congress has acted, clearly, repeatedly, and on a bipartisan basis. the president now has the duty to follow the laws he himself signed. it shouldn't be that hard when you consider his admonition yesterday about upholding the highest standards of the rule of law. as americans, he said, we pride ourselves on being a beacon to other nations, a model of the rule of law, the president said. and that's interesting in light of a recent g.a.o. ruling that the administration's detainee swap of taliban prisoners for bow bergdahl violated the law. it's especially interesting in light of the president's continuing refusal to rule out breaking the law if he doesn't get his way on guantanamo. presidenpresident obama's own ay general says he can't unilaterally do that. it's clear. president obama's own defense secretary says he cannot unilaterally do that. president obama's own military officer says he can't unilaterally do that. in the words of one of our democratic colleagues, he's going to have to comply with the legal restrictions. as simple as that, going to have to comply with the legal restrictions. breaking the law is the way to supposedly uphold the rule of law is just as absurd as it sounds. it's time the president finally rule that option out categorically. and then he should finally move on from a year's old plain promise and focus on the real problems that need solving today. my own hope is that the commander in chief will not put his own in the position of having to carry out an unlawful direct order. but, look ... closing guantanamo and transferring terrorists to the united states didn't make sense in 2008, and it makes even less sense today. we're a nation at war. the administration's efforts to contain isil thus far have not succeeded. the next president may very well want to pursue operations that target, capture, detain, and interrogate terrorists, because that's how terrorist networks are defeated. why would we take that option away from the next commander in chief now? and let's be clear ... the two options on the table are not keeping guantanamo open or closing it but keeping guantanamo terrorists at guantanamo or moving them to some guantanamo north based in a u.s. community. changing the detention center's zip code is not a solution. it's not even serious. the fact that the president missed a deadline for submitting a plan to defeat isil last week presumably because he was just too busy working on his ancient campaign promise is just completely unacceptable. now, some of the most senior national security officials within president obama's own administration are already working to better position the next president for the national security challenges that we will face in 2017. it's time president obama finally joined them and us in the serious work of keeping americans safe in a dangerous world. mr. president, we're going to move the confirmation vote back closer to noon in order to accommodate some important hearings that are going on this morning in several of our committees. mr. reid: mr. president? the presiding officer: the democrat leader. mr. reid: yesterday the senior senator from iowa, along with other republicans on the senate judiciary committee, announced that they won't be holding a hearing on president obama's eventual nominee to the supreme court. they won't give the eventual nominee the common courtesy of even a meetin meeting. no hearings, no meeting. and this is all done even before the president has sent a name to us. this is historically unbelievable and historically unprecedented. the republicans don't know who the nominee will be. i've already mentioned that. already they've disiewded that they won't give -- already they've decided that they won't give the confirmation process even a start. why? because a person was nominated by president obama. remember, the republican leader said many years ago, the number-one goal he had was to make sure that president obama was not reelected. that failed miserably. the president won by more than 5 million votes. and everything has been done by the republican -- the republicans in the senate to embarrass, obstruct, filibuster, anything that can be done to focus attention on president obama, none of which has helped the country. but senator grassley has surrendered every pretense of independence. he let the majorit -- so partist that the senior senator from iowa won't respond to a personal invitation from the president inviting him to the white house to discuss the vacancy p. think about that. the president of the united states calls a very senior senator here and doesn't even repond to the president. this is a sad day for one of the proudest committees in the united states senate. so i ask, is this the legacy that he wants? is this how he wants his committee work remembered, as a chairman who refused his duty and instead allowed the republican leader to ride roughshod over the jurisdiction of the committee chairman. the strengths of the judiciary committee in senate have been legendary. no majority/minority leader could tell a chair what to do with his committee. that was off-balance. but it doesn't appear so now. in abdicating his responsibility, the senate has always held republicans -- has always upheld -- never in the history of the cou, has the senate ever refused to do anything. republicans are setting a dangerous precedent for future nominations, not only for the supreme court but for the senate itself as an institution. yesterday the senate historian's office reported that the denial of committee hearings for a supreme court nominee is unprecedented. if that's unprecedented, how about the fact you won't even meet with the person who's been nominated? if that's -- if that is unprecedented, how about the fact that a member of the united states senate won't even go to the white house to talk to the president about something about filling the supreme court seat? the senior senator from iowa will be the first judiciary chairman ever to refuse to hold a hearing on a supreme court nominee. that's quite an achievement. but none should make him very proud. this sort of wasn' wanton obstrn is not what the american people want. it is not what the people of iowa want. last week no more than six iowa newspapers issued scathing editorials calling on senator grassley to change course and give the president's supreme court nominee the respect he or she deservings. -- deserves. the "may son city globe gazette" wrote, "we were disappointed to see iowa's own chuck grassley join the partisan crowd calling for delay. there's no constitutionally historical precedential for such a shameful and bold-faced partisanship." the "gazette" in cedar rapids wrote of his actions, "it's hard to conclude this is anything but political maneuvering meant to meet partisan objectives at the expense of the supreme court. our constitutional process and the common good." "the des moines register" read, "suprem"senator grassley's supre court stance is all about politics." mr. president, is that the legacy the chairman wants for or iowa and our nation? i hope not. does he want to be remembered as the least productive judiciary chairman in history? at his current pace, he will be remembered as the most obstructive. senator grassley should take note of what senator biden did 25 years ago or generally as a member and chairman of that committee. in 1992 the judiciary committee under his leadership, senator biden's leadership, confirmed 64 circuit and district court nominations. all of the judicial nominations were made by a president from the opposite party. president george h.w. bush. in 2015, senator grassley's first chair as chairman of the judiciary committee, the senate confirmed 11 judicial nominations. that was the fewest judicial nominations confirmed ever. we -- forever might be a bit mu. that's quite a comparison. biden, 64. grassley, 11. but it even gets worse than that for my friend from iowa. in the entire 102nd congress, when joe biden -- joe biden as chair, the senate confirmed 120 nominees, 120 judicial nominations under biden. 11 under chairman grassley. the difference is stunning. i would encourage my friend from iowa to focus on chairman biden's actions and results rather than cherry-picking remarks. the judiciary committee of joe biden honored its nomination by confirming and visiting with nominees in a timely fashion even though they were a republican president's nominees. i can't say the same of the committee today. as chairman, joe biden did his constitutional duty to process four nominations for republican presidents for the supreme court. justice kennedy, that was the last year of reagan. that vote occurred in the last year of president reagan's presidency. souter and thomas. let's fowms -- focus on thomas for just a little bit. thomas got 52 votes. he squeaked through the senate. any one senator could have forced a cloture vote. any one democrat could have done it. we didn't do that. it was never done until the republicans showed up here in the last few years. now bork, a very controversial person, received a long, long hearing before the committee and a long debate here in the senate. and he was voted down. that's the way this place is supposed to work. other nominations have been voted down. but we didn't, with bork, we didn't say we're not going to hold a hearing on bork. we didn't say we're not going to take the committee's actions and leave it at that. listen to this, bork was turned down in the judiciary committee by an overwhelming margin, but in spite of that we brought it to the senate floor and there was a debate and he won by two votes. no filibuster. he was defeated in the committee. we didn't look for an excuse. that isn't the way it used to be done. this now -- the republican leadership now, they won't meeth the nominee, they won't hold a hearing and the chairman of the committee won't even go to the white house and visit with the president. as chairman, senator biden did his constitutional duty and processed nominations, even though they were republican nominations. so we don't have to go back to 1980 or 1982 to prove the current chairman's ineptness. look at the spike in judicial emergencies that occurred on chairman grassley's watch just in the past year. what is an emergency? it means there aren't enough judges -- too many cases for a judge to do the work. a vacant judgeship is automaticically declared an emergency as it should be. when republicans controlled the senate last year there were 12 emergencies nationwide. today, a year later, that number has almost tripled to 31. by nearly every metric, the judiciary committee under chairman grassley is failing dramatically, setting all records of failure in this great body. the committee is failing the people of iowa and the nation. to the senator from iowa, the senior senator from iowa, i stress, i plead don't continue down this path. reject this record-setting obstruction and simply just do your job as a powerful chairman of the judiciary committee. mr. president, i see no one on the floor. would you announce the business of the day? the presiding officer: under the previous order, the leadership time is reserved. under the previous order, the senate will resume executive session to consider the following nomination which the clerk will report. the clerk: nomination, department of health and human services, robert mckinnon califf of south carolina to be commissioner of food and drugs. mr. reid: mr. president, i would note the absence of a quorum. the presiding officer: the clerk will call the roll. quorum call: the presiding officer: the senator from arkansas. mr. cotton: i ask unanimous consent that the quorum call be lifted. the presiding officer: without objection. mr. cotton: i ask unanimous consent that the confirmation volt scheduled for 11:00 a.m. this morning be moved until 12:00 noon with all other provisions of the previous order remaininremaining in effect. the presiding officer: without objection. mr. cotton: i suggest the absence of a quorum. the presiding officer: the clerk will call the roll. quorum call:

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