Transcripts For CSPAN3 Politics Public Policy Today 20140710

Email from a Fourth Amendment perspective in part that he feared if it doesnt count that should eliminate the protection of privacy. That is, to the extent we a lhaa lot of robots looking at our email to scan it for viruses or to service ads or whatever, if that counts and weve agreed to that or otherwise have allowed that, that could mean we have given up our overall interpretation of privacy in those communications. I fear that toxin was killing the Fourth Amendment to save it. I think im more concerned about the parables that come from government surveillance than private surveillance and i think our allowing that kind of behavior does not eliminate protection of privacy, and we have enough cases saying that that i feel comfortable. But its not that easy. It gets to the automation rationale which is the case where smithfield, maryland said we do not have enough cases to judge. I think this goes to age bias as much as anything else. They said, human operators used to connect our calls, and the fact the phone companies have automated that process doesnt change the fact we have exposed that information to the phone company. We pivot that and use that to our advantage in the paper and say, well, if its good for the goose, its good for the gander. The fact the government is auto ma mating this reading doesnt make it less of an advantage. Thats right, and i think another way of sort of restating this or maybe adding a bit to it that kelly and andy could answer the question is that we agree with you, neil and michael and woody, that the real genius of our paper is not the use of the word robots in the title but is the use of the word agent. Because we talk about the National Security agency and that National Security agency has agents, and some of them are human beings and some of them are Software Agents. Maybe some of them are scary robots, too. And those agents follow out the wishes of the principal, and it doesnt matter whether those wishes are accomplished through a Software Agent or a human agent or a scary killer robot agent. What matters is that the agency is happening. And the will of the principal is being a feffectuated through onf its agents. When michael said i dont have any privacy anymore because everything is being tracked, there is something that says we respect an expectation of privacy that people have, subjective, and also one that people accept as reasonable in an inquiry. If there isnt an expectation anymore, privacy goes away. There are two things we can do. Junk the perspective entirely, which i think we can do, and when it comes to objective reasonableness, we should look to lawyers. Lawyers, doctors, priests or librarians or psychotherapists, anybody who has a professional duty of confidentiality. When you trust someone with your data, your lawyer, lets say, this might be publicly known information but they are under a duty as your agent not to disclose under any circumstances. It doesnt matter whether the person asked the question knows whats going on, it doesnt matter really anything, and thats the way the agency can be used as a sword, that it can protect confidences, it can protect sharing. Ironically enough so that sharing can take place. It occurred to me that over the last 200 years, theres been a massive erosion in the publics concern with privacy. Because if you think about what our founders were trying to do with the bill of rights in protecting our papers and effects and preventing the interception of our mail, essentially the free ice cream that we get when we sign up for google or hotmail or Something Like that lets us sacrifice the privacy youve heard the free ice cream theory, right . I dont get the ice cream. Oh, sorry. There is a little bit of a theme, i guess, in privacy discussions on articles and stuff, they call it the free ice cream problem. That people will accept any crazy terms of use, including indemnification of the service that theyre providing and limitation of liability to the amount of their subscription, and they will do anything for the free ice cream. Thats the saying that is going around. If people are thinking, okay, ill click i accept these insane terms of use and sacrifice my firstborn and my arm and my leg, that is the reason why this expectation of privacy just kind of disappeared, then the only people who are terrified are the lawyers, right . Because the lawyers are thinking, how do i defend my client in court when the contents of every email that theyve ever sent are exposed for consideration . Thats one thing. How do we expose this problem to the general public and inspire them to be outraged in the same way that our founders were outraged, in the same way that the british were outraged when the Castle Doctrine originated . And how do we manage the problem of the destruction of a persons life during a multiyear litigation when you may finally get this critical piece of evidence that was acquired by violating the privacy kicked out of the lawsuit, but the person has basically been dragged through the mud in the public eye . I wont speak for kevin because hell noriel at me, but i get this privacy dead question a lot, like do people not care about this anymore . My experience is if they dont care, they dont know. To the extent they do, i agree with kevin on his point earlier that quit being a narcissist. But also because you talked about a multiyear litigation, i just had to go through this with my sister who lives in florida and had to be told her Facebook Messages could be subpoenaed, even her private messages. And she had no idea, which is an interesting place to put someone when they start thinking about what is private and what is public. You have to put it in context, is that people may give up their privacy but they give it up contextually and they dont understand that information can leave the context that you put it into. So i think there are a lot of psychological pieces that go into that that go outside the law, and lawyers are used to thinking of it in very rigid, specific instances and not really the way you think about it in everyday life. Kevin is right, its you will about power. But its all about power on the consumer expectation, too. The reason papers are in the Fourth Amendment wasnt because people were concerned about the government rummaging through their things, but they were rummaging through their things to find diaries or letters or evidence that could be used to punish or haul people in courts on charges of treason because it was very much a public liberty. I think thats part of the argument as well, but its an argument that we should care about the Fourth Amendment because we care about a Government Society. This might be controversial, it might be wrong, but ill say it, anyway. Its more important to have a Government Society than to have free ice cream. On the commercial side, its also a question of power. Amy is exactly right, its a question of limited choices. Its a question of knowledge and information. Where we have that elsewhere in the consumer context, we regulate it. That might be practically difficult to accomplish, but thats the answer, and i think thats the story we need to tell. These are all about stories. I just want to know if somebody from microsoft and google are here giving out ice cream. I want my ice cream. First of all, you two are my favorite country lawyers. Or at least kevin is, im not sure amy is from the country. She said she is. I think you should use that perspective actually more. Im going to push back against neal. The litigator perspective . Yeah. Actually, youre uniquely situated for the litigator perspective. Kevin, something you said earlier struck me which is this is all about trying to get these issues into court. I looked to see if amnesty is included, and i couldnt find it. If this is about power, which i agree it is, the very complex series of hurdles that you have to overcome to even get to the question thats a lot of series. Right, but if youre about power, this is like that last piece in all the other pieces of the system, which i think is a really important part of it. Im just here to control neal because im still mad at him for saying we should treat robots like drivers a few weeks ago . I think the real problem is its not about robots, and its maybe not right to use robots in this context. I agree with that, but we talked so much about how people perceive robots as agents and how we have these completely Unrealistic Expectations from science fiction, and it just sounds so different. A robot is reading your email versus your emails being automatically scanned, and so if were talking about getting people to care about privacy d and, you know i dont know, im just trolling, basically, but if you had to choose between being intellectually honest and having people actually care about these issues, what would you pick . Thats directed at neal. I want to say like based on this that i just added in, what were talking about, they are robots. Theyre certainly bots. Would take the ro off make people happy . So when did i stop beating my wife is the loaded question youre asking me. I dont think its intellectually dishonest to call it robots, and i want to be clear because that was one of my critiques of kevin on this paper. I dont think its intellectually dishonest. I think using the word agent is better. My concern about using at a tactical level using robots to get people to care is we may get people to care about the privacy issue, but then we create this whole anthropomorphic level, and we create a huge robotics problem with the anthropomorphic problems that the people yesterday were talking about. When i say robots are hammers metaphors are hammers, too, and hammers are good. We should just be clear that these are human construction tools. Hammer is probably a colorful way of expressing it. Toasters are even a more metaphorphic way of expressing it. All of us are engineers and we just want to build good things. We can argue what good is, but ultimately thats all we have to realize. There is no mystery to this, its just hard. Thats why were here. Thats all very much. I have two quick announcements. The first is we have tshirts for sale out front. If you want them they have the wonderful symbol of rosie the roboter. And this is the last chance to sign up for car action at the airport if you need that. Having done that, i now have the fun part of thanking you for joining this wonderful panel. It was a great panel. [applause] thank you. Well see you in 15 minutes sharp. Were live this morning on capitol hill where we expect a hearing to get under way shortly which will explore the effectiveness and the access to the vas Mental Health and Suicide Prevention programs. A 2012 suicide data report released by the va found that 18 to 22 veterans per day commit suicide despite increases, significant increases, in the departments Mental Health and Suicide Prevention Budget Programs and staff. Members of the House Veterans Affairs committee will hear this morning from Veterans Health administration officials, Mental Health experts, family members of veterans who killed themselves and others. Congressman jeff miller of florida is the chair and representative mike mishu of maine is the Ranking Member. Also youll get a chance throughout the day, if youd like to give us your reaction, you can use facebook and of course twitter with the hash tag cspan chat. If i could get everybody to take their seats, please. Welcome to order. Before we begin, i would like unanimous consent for our colleagues representative scott peters from california and pierson cinema from arizona to sit in and participate in the proceedings today. Without objection, so ordered. Id like to welcome everybody to todays full Committee Oversight hearing entitled service should not lead to suicide, access to vas Mental Health care. Following widespread manipulation and physical harm in facilities all across this nation, this committee has held a series of Oversight Committee hearings over the last several weeks to evaluate the systemic access and integrity failures that have consumed the Va Health Care system. Perhaps none of these hearings have presented the alltoohuman face of vas failures so much as todays hearing will, in fact, do. A hearing that i believe will show the horrible human costs of vas ddysfunction, and i dare say, corruption. At its heart, access to care is not about numbers, it is about people. Recently the Committee Heard from a veteran who had attempted to receive Mental Health care at a va communitybased Outpatient Clinic in pennsylvania. This veteran was told repeatedly by the va employee he spoke with that he would be unable to get an appointment for six months. However, when that employee left, another va employee leaned in to tell this veteran that if he just told her that he was thinking of killing himself, she would be able to get him an appointment much sooner. In just three months instead of six. Fortunately, that veteran was not considering suicide. But what about those veterans who are . How many of the tens of thousands of veterans that va has now admitted have been left on waiting lists for weeks, months, and even years for care were seeking Mental Health care appointments . How many are suicidal or edging towards suicide as a result of the inability to get the care they earned. Despite significant increases in vas Mental Health and Suicide Prevention programs and staff in recent years, the suicide level of veterans has remained more or less stable since 1999, with approximately 22 veterans committing suicide every single day. However, the most recent va data has shown that over the last three years, rates of suicide have increased by nearly 40 among male veterans under 30 who use Va Health Care services and by more than 70 among male veterans between the ages of 18 and 24 who use Va Health Care services. This morning were going to hear testimony from three families, the somers, the portlies and [ inaudible ] they sought medical care after combat. Each of these men hit barrier after barrier to getting help. Each of these young men su succumbed to suicide. In a note, one wrote he felt the government had abandoned him and came home to face a system of dehumanization, neglect and indifference. Va owed daniel and clay and brian so much more than that. With that i yield to our Ranking Member, mr. Misho, for his opening statement. Thank you so much, mr. Chairman, for holding this very important hearing. We have had many discussions and debates about how to deliver the best Health Care Services to our nations veterans and how to ensure accountability within the leadership ranks of the department of Veterans Affairs. Over the course of these recent hearings and discussions, we have touched on important issues, but one we havent zeroed in on yet is access to Mental Health care and Suicide Prevention services for our veterans. Thats why this hearing today is so important. Id like to thank all the panelists for joining us today, but particularly i want to thank the family members joining us who have lost a loved one. I know theyre speaking about a loss of a loved one, particularly a child, can be an incredibly difficult and exhaustive experience. But in this case i think we have to listen to your stories, identify what went wrong, and we can take action to ensure that those failures arent repeated again. So i want to thank you very, very much for joining us today to share your stories. 18 to 22 veterans commit suicide each day. In my opinion, that is 18 to 22 brave men and women each day who our system hazls let down in so capacity. It is totally unacceptable. When a veteran has experienced depression or other Early Warning signs that may indicate Mental Health issues or even suicide, that must be treated like immediate medical crisis because thats exactly what it is. Veterans in that position should never be forced to wait months on end for medical consult because, quite frankly, that is time that they may not have. We have taken steps to help put in place programs and initiatives aimed at early detection, and we have significantly increased our funding. The department of Veterans Affairs funding of Mental Health has doubled since 2007, but its not working as well as we had hoped and we have to figure out why and how we can correct these problems. Our veterans are the ones paying the price for this dysfunction. A 2012 ig report found that va data, on whether it was providing timely access to mental services, is totally unreliable. In a go report from that year not only confirmed that finding but also confirmed that va scheduling made it difficult, if not impossible, to get patients the help they need when they need it. That is why we have to look at this situation. That is a problem that we have seen repeatedly as we dig into the vas dysfunctions, and enough is enough. Our veterans and their families deserve a va that delivers timely Mental Health services that cover a spectrum of needs from ptsd, counseling for family members to veterans, to urgent roundtheclock response to a veteran in need. A recent va ig report found that in one facility patients waited up to 432 days, well over a year, for care. So once again, we are finding that our veterans deserve much better than the care they are receiving in all the areas we must address. We have to look at it comprehensively, and i would argue that fixing Mental Health services is among the most important area. I look forward to a productive discussion that will begin today as we look forward to trying to solve some of the problems with a Dysfunctional Department weve seen over the last several months. Once again, mr. Chairman, i want to thank you very much for having this very important hearing and for the panelists for coming today to tell your story. With that i yield back the balance of my time. Thank you very much to the Ranking Member. Were humbled and honored to be joined by our first panel of witnesses this morning. Family members of the three veterans who sadly and tragically lost their lives to suicide. And im sure that i speak for each of my colleagues when i say that each of you have our deepest sympathies to you for your loss. I am both grateful, and at the same time angry that you have to be here to share your stories of your sons with each of us. So if you could approach the witness table, please. Joining us is dr. Howard and jean somers, parents of Daniel Somers, susan and richard selky, the parents of clay hunt, and peggy portwine, mother of Brian Portwine. We are also joined on our first panel by josh renchler, a veteran of the United States army who will share his very important story of attempting to seek Mental Health care with the department of veteran affairs. Thank you for being here today. Dr. Somers, please proceed with your testimony. Ranking member michaud and committee members. Were touched to be able to testify here today. Were glad to be seeing our own california representative scott peters and mr. Sila who have been with us along the way to help with the experiences of our son. Our nightmare started january 15 when daniel came back from his Second Service of combat in iraq. He suffered traumatic brain injury and gulf war syndrome. Daniel spent six tragic years trying to access the va health and benefit systems before finally collapsing under the weight of his own despair. We have attached the story of Daniel Somers to our testimony which provides the details of his efforts, and we hope you will read it if you have not already done so. Today it is our objective to begin the process which will ultimately provide hope and care to the 22 veterans a day who are presently ending their lives. Just over a year ago and four days after daniels death, feeling fortunate that we at least had a letter from him, howard and i howard is a urologist and i spent 30 years in the business of health care sat down with daniels wife who is a bachelor of science and nursing, and his mother, who is a psychiatrist. Together we felt uniquely qualified to prepare a 19page report that we entitled systemic issues at the va. We have shared that document with several of you in the last year, and it is also attached to our testimony. The premise of the report remains the same as when we wrote it, to improve access to firstrate health care at the va, to make the va accountable to veterans it was created to serve, and to make every va employee an advocate for each veteran. At the start, daniel was turned away from the va due to his National Guard Inactive Ready reserve status. Upon initially accessing the va system, he was essentially denied therapy. He had innumerable problems with va staff being uncaring, insensitive and adversarial. Literally no one at the facility advocated for him. Administrators frequently cited hepa for the reason of not involving family members or using modern technology. Vista is at least inadequate. It impedes access and lacks basic documentation. The Va Information Technology infrastructure is antiquated and prevents agencies from sharing critical information. There is a desperate need for come ppatiblility between the vd the add. There was no succession planning no procedures in place for warm handoffs, no contracts in place for local tenems and a fierce outsource for helping anyone or anything. At the time daniel was at the phoenix va, there was no Pain Management clinic to help him with his chronic and acute fib ro fibromyalgia pain. There were few goals, policies and procedures. The fact that the formularies at the va were separate and different makes no sense. Since many were stabilized on a particular regimen, they must rejustify their needs when they transfer to the va. There were inadequate facilities and an inefficient charting process. There was no way for daniel to ascertain the status of his benefits claim. There was no vha, vba appointment interfacing nor proactive procedures. There was no communication between disability determination and vocational rehabilitation. This report is offered in the spirit of a call to action and reflects the experiences of daniel with va Program Services beginning in the fall of 2007 until his death last june through our eyes. As seen through our eyes. Our concern then was that the impediments and deficiencies were a sign of deeper and broader issues within the va not serving a broad number of veterans. Unfortunately, it has proven true after dramatic revelations of recent announcements. They will provide funding with the va, but with that new funding should come greater scrutiny and a demand for better measurable results. There is, however, an alternative to attempting to repair the existing broken system. We believe congress should seriously consider fundamentally revamping the mission of the Va Health System. In the new model we envision, the va would transition into a center of excellence specifically for warrelated injuries while the more routine care provided by the rest of the Va Health System would be open to private Sector Service providers, much like tricare. That approach would compel the current motto to selfimprove and compete for veterans business. This would ultimately allow all veterans to seek the best care available while allowing the va to focus its resources and expertise on the treatment of complex injuries suffered in modern warfare. We thank you for your time and would be happy to further discuss our recommendations and suggestions. We sincerely hope the systemic issues brought here would allow communication between lawmakers, administrators of comprehensive reform and review of the entire va process. And if the va committee or congress as a whole make a decision to involve other stakeholders in a more formal process, we would be honored to be among those chosen to represent the views of affected families. Thank you. Thank you both for your testimo testimony. Mr. And mrs. Selky, youre recognized. Thank you, chairman miller, Ranking Member michaud and distinguished members of the committee. Thank you for allowing us to talk to you today about the topic of limited access at the va and especially about the story and experience of our son clay. My name is susan selkie and im accompanied here today by my husband richard. Im the son of a marine corps combat veteran who died in march 2011 at the age of 28. Clay entered the marine corps and served in the infantry. In 2007, he was sent close to volusia. He was shot in the wrist by a snipers bullet that barely missed his head. After he returned to california to recuperate, clay began experiencing many symptoms of postTraumatic Stress, including panic attacks, and was diagnosed with pts later that year. Following the recuperation from his gunshot wound, clay attended and graduated from the marine Sniper School in 2008. He was deployed again, this time to southern afghanistan. Much like his experience during his deployment to iraq, clay witnessed and experienced the loss of several fellow marines during his second deployment. Clay received a 30 disability rating from the va for his pts. After discovering that his condition kept him from maintaining a steady job, clay appealed the rating, only to hit several barriers, including the va losing his files. Five weeks after his death, clays appeal finally went through and the va rated clays pts 100 . Clay exclusively used the va for his medical care after separating from the marine corps. Immediately after the separation, clay lived in the Los Angeles Area and received care at the center there in l. A. He constantly voiced concerns about the care he was receiving, both in terms of the challenges he faced with scheduling appointments as well as the treatment he received for pts which consisted primarily of medication. He received counseling only as far as a brief discussion regarding whether the medication he was prescribed was working or not. If not, he would be given a new medication. Clay used to say, im a guinea pig for drugs. Theyll put me on one thing, ill have side effects, and they put me on something else. In late 2010, clay moved briefly to Grand Junction, colorado where he also used the va there, and then finally home to houston to be closer to family. The houston va would not refill the prescriptions that clay had received from the Grand Junction va because they said the prescriptions were not transferrable and a new assessment would have to be done before his medications could be represcribed. Clay had only two appointments in january and february of 2011, and neither was with a psychiatrist. It wasnt until march 15 that clay was able to see a psychiatrist at the Houston Va Medical Center. But after that appointment, clay called me on his way home and said, mom, i cant go back there. The va is way too stressful and not a place i can go. Ill have to find a vet center or something. Just two weeks after his appointment with the psychiatrist at the Houston Va Medical Center, clay took his life. After clays death, i personally went to the Houston Va Medical Center to retrieve his medical records, and i encountered an environment that was highly stressful. There were large crowds, no one was at the information desk, and i had to flag down a nurse to ask directions to the medical records area. I cannot imagine how anyone dealing with Mental Health injuries like pts could successfully access care in such a stressful setting without exacerbating their symptoms. Clay was consistently open about having pts and survivors guilt and he tried to help others coping with certain issues. He worked hard to move forward and found healing by helping people, including participating in humanitarian work in haiti and chile after the devastating earthquakes. He also starred in a Public Service Advertising Campaign aimed at easing the transition for his fellow veterans, and he helped Wounded Warriors in longdistance road biking events. Clay fought for veterans in the halls of congress and participated in iraq and iran veterans storm hill in 2010 to advocate for legislation to improve the lives of veterans and their families. Clays story details the urgency needed in addressing this issue. Despite his proactive and open approach to seeking care to address his injuries, the va system did not adequately address his needs. Even today we continue to hear about both individual and systemic failures by the va to provide adequate care and address the needs of veterans. Not one more veteran should have to go through what clay went through with the va after returning home from war. Not one more parent should have to testify before a Congressional Committee to compel the va to fulfill its responsibilities to those who have served and sacrificed. Mr. Chairman, i understand that today youre introducing the Suicide Prevention for American Veterans act. The reforms, evaluations and programs directed by this legislation will be critical to helping the va better serve and treat veterans suffering from mental injuries from war. Had the va been doing these things all along, it may very well have saved clays life. Richard and i again appreciate the opportunity to share clays story and about recommendations we can ensure the va will uphold its responsibility to properly care for americas veterans. Thank you. Thank you both for your testimony this morning. Mr. Portwine, youre recognized for five minutes. Thank you, mr. Chairman, mr. Michaud, distinguished committee members. My son Brian Portwine gave 100 to every task he performed and his military service was no exception. By the time he was 19 years old, brian was awarded the purple heart and the Army Commendation medal. At 17 brian enlisted in the army. After his training in infantry, he was sent to baghdad where he patrolled on the streets. It was an extremely daunting service. This occurred before the surge of troops. During this tour, brian lost 11 brothers. While serving in iraq in 2006, brians tank was struck by an rpg. The flames quickly engulfed the tank, the driver was knocked unconscious and the men fought for their lives as the driver was unable to hiydraulically lower the ramp. Brian lowered the ramp and they escaped with injuries. Brian suffered cuts to his face due to shrapnel and brain injury. On another mission, brian and his First Sergeant were patrolling in a humvee when his sergeant asked brian to switch seats with him. Brian was now in the passengers seat. 20 minutes later, they hit the humvee on the drivers side and he was thrown from the vehicle. This was all within six weeks of his deployment. I pause here to ask, isnt this enough to warrant a further evaluation and testing . The powers that be apparently thought of sending brian to Walter Reed Hospital but didnt. Arent these experiences with the physical and mental injured enough to possibly exempt him for another deployment . Apparently the va felt his care was iffy and stamped a no go on his clearance form, but then it was crossed out and written go. How and why this decision was made is beyond me. After his first deployment, brian was ecstatic to be home again. He enrolled in daytona state college, he worked in the admissions counseling office, he created videos to share resources with students, hosted events and linked students with parttime employment around their school schedules. But brian suffered with shortterm memory loss. He would have to write everything on his computer, his iphone or his calendar. Many times his friends told me when he was out with them he would say, where are we going again . You know ive got scrambled brains from iraq. To help cope, he posted all his events on his computer, his calendar and his phone. In 2010, the military recalled brian one month before the college year ended. Brian immediately dropped his classes that he excelled in. When i asked him why, he said, mom, there is no point. You have to get your mind in a completely different place. You have no idea whats coming. During the second deployment, brian didnt email or call to any family or friends. Little did we know how he was struggling with anxiety attacks, panic attacks, traveling the same roads as the first tour. He knew the stigma of admitting ptsd as all soldiers do, so you just man up and move on. Upon returning from the second deployment, brian was evaluated. He was diagnosed with ptsd, tbi, depression and anxiety. At this time id like you to refer to the documents you received, brians medical documents. Its a document that brian couldnt remember the questions asked from the therapist during the interview. He had extensive back pain, he couldnt sleep, he felt profound guilt, he suffered from low selfesteem, and as a result, he was a risk for suicide. Nonetheless, he was immediately discharged and told to follow up. How in the world you can ask someone who cant remember the questions asked to follow up with the va is beyond me. Brian deteeriorated quickly fro december 2010 to may 27, 2011 when he took his life. He couldnt stand how he would be angry, depressed, anxious but he didnt know how to cope. It took a toll on his relationships. If the d. O. D. And va assessed brian for suicide risk, it was their duty to treat him, but they did nothing. He applied for disability but was unable to wait. Brians unit has lost three others besides himself to suicide since the 2006 to 2008 tour. As you know, suicide surpassed combat fatalities for the first time in history. Its a very slippery slope from ptsd and tbi to death, something our va should realize. Our soldiers never hesitated in their mission to protect, serve and sacrifice for our country. Now its time for the va to prove their commitment to our soldiers. I never knew of brians pts, tbi or suicide risk. I think he felt if i can survive two tours of iraq, i can survive anything. I think its a lifethreatening situation like this and it should be shared with the family so we are able to help. The va needs to work with the service organizations, including the families in the plan for care. Im requesting, im begging this committee to pass act 2182, the save act. This has been a most devastating wore in history war in history in terms of suicide. Our nation continues to suffer every day. We continue to lose 22 brians a day. I promise mid son at his funeral that i would stop this injustice. These are quality young men who potentially had so much to offer society. Please pass this act 2182 and support any legislation that gives our soldiers the timely and loving care that they deserve. Thank you. Thank you, ms. Portwine. Sergeant wrenchler, youre recognized for your statement. Chairman miller, Ranking Member michaud, members of the committee, i appreciate the opportunity to discuss va Mental Health care, and i certainly want to acknowledge the loss and the courage of these family membe members, ensuring that this wasnt in vain, and i struggle with the severity of the stories. As an infantryman who lost so many in the iraq war and injured and struggled with the loss of suicide from chronic pain and other injuries, i just thank you all for being here. My experience with the Va Health Care system began in 2008. Sorry. Its okay, youve got plenty of time. After i was medically retired from the army due to severe injuries from a mortar blast in iraq excuse me. Ive been a patient but im also an advocate for other warriors who are struggling with deploymentrelated traumas. For a period of about 12 months, i did receive excellent Mental Health care at a va facility. It provided easy onestop access through Deployment Health models staffed by Mental Health, pharmacy and social work providers. Unfortunately, though, hospital administrators decided this wellstaffed interdisciplinary care was too costly. Now veterans at the facility go through a personal intake assessment process and have to find their way around a stra sprawling facility pto access te care that they need. Wandering ty is enough stress in itself. They will seldom open up and discuss private issues with a clinician theyve never met. Theyre more likely to describe surface level issues, like difficulty sleeping. It takes time to build a trust to talk about the deeper issues. And not every clinician is skilled at winning the trust or insightful enough to sense when there is deeper problems. Working with a team increases the likelihood of someone to see something that others may have missed. This is implications for Suicide Prevention as well. Veterans will rarely volunteer to clinicians that theyre contemplating suicide. And there arent necessarily obvious signs that a veteran is a suicide risk. One thing is for sure, we wont prevent suicides by doctors mechanically going down a mandatory list asking questions like, have you contemplated suicidal thoughts lately or harming others . Sometimes there is red flags an astute clinician can spot, like the breakup of a relationship or other major life events that can lead a person to take a desperate act. In a treatment system where i get sent to building 3 for neurologist for chronic back pain, building 61, to see a psychiatrist for sleep problems and building 81 to see a social worker for relationship issues, no one is getting the full picture. So it is likely that no one is going to see if my life is spinning recklessly out of control. As an integrated health care system, the va can provide the kind of care i once received from an Interdisciplinary Health team. There the team members shared observations and can see potential problems before they became explosive. So i think that the most important step that the va can take to prevent suicide is to dramatically improve its Mental Health care delivery. Access is certainly an issue, but we have to ask ourselves, access to what . Access to Mental Health care isnt enough unless that care is effective. For example, providers who work with combat veterans need to understand the warrior mentality, and they may have to work hard to win that veterans trust. If a clinician lacks that wareness or has too many patients to give each enough time, veterans will get frustrated and drop out of treatment. Veterans that arent ready for therapy will drop out of the multiweek treatment programs even though theyre hailed as evidencebased therapy. The bottom line is that the va care must be veteran centered. That has to mean recognizing each veterans unique situation, and individual treatment preferences and building a flexible system to meet the veterans needs and preferences. Not the other way around. The warriors that im describing dont come at a treatment for pt ptsd or anxiety because the text books say they should. Most dont come in until they have reached a crisis point in their lives. Certainly a veteran in distress who finally asks for help for combat incurred Mental Health condition needs to get into treatment immediately. But we wont solve that problem by establishing an arbitrary requirement like a 14day rule. It doesnt help a warrior at the end of his rope to get assessed within 14 days but not begin treatment within three months. This is the way that the va is currently implemented such policies. They have added additional steps to get into treatment, so that you can see someone within 14 days, they added a second intake process, so now you intake to intake to finally get the treatment you need. I know that some believe the way to solve the veteran problem is to expand veterans access to nonva care. I really personally doubt thats any kind of Silver Bullet solution. The two big concerns with that is, first detailed in my full statement, many reports and studies point to a National Shortage of Mental Health providers within the community. Secondly, there is real quality of care issues here. Va could certainly benefit from a greater use of purchase care, where and when it is available, and when it can be effective. But it wouldnt help veterans just to be seen by providers who arent equipped to provide effective care. Whether because of lack of training and treating combatrelated ptsd or cultural competence or any other reason. Again, it is not just a matter of access, but access to what. It has to be effective treatment. I do believe that there are va facilities that are providing veterans with timely access to effective patient centered care, but it is not system wide. For my perspective, the starting point for va leadership at all levels is to adopt the principle that providing timely, effective Mental Health care for those with serviceincurred Mental Health conditions must be a top priority. The va achieve that with its efforts to combat veteran homelessness recently. That tells me the va can have a real impact when the direction and priorities are clear. When artificial performance requirements dont create distortions, and when clinicians have latitude to provide good care. Improving Mental Health care definitely requires the comprehensive approach. One part of that approach in my view should be to institute the kind of interdisciplinary teambased model i described earlier, but the core of any approach has to center on the veteran and that patients needneeds and preferences. We need a system that serves the veteran, not one that requires the veteran to accommodate the system. I hope that this hearing brings us a step closer to that kind of va care system. And i thank you for the time and i would be happy to answer any further questions that you may have. Thank you very much, sergeant. Thank you, again, to all the witnesses. Sergeant, if i could go back to you since you were the most recent person to testify, you talked about the Interdisciplinary Care Team that you had for 12 months. And then after that, you alluded to the fact that the hospital director or somebody said that it cost too much to do it that way. I think we would all benefit from you elaborating a little bit about how that occurred and what did you transfer to what type of a care . Yes, sir. In 2008 until 2009, the va rolled out, i believe, four different Deployment Health care models nationwide. The Deployment Health care model that i speak of was one that was rolled out Washington State for the American Lake va medical center. And it was put together by dr. Steve hunt with the va. And this model provided one wing of a hospital floor in which an Interdisciplinary Care Team for Deployment Health post 9 11 veterans exclusively that had a pharmacist, social workers, psychiatrist, psychologist, and primary care on one team and weekly they would meet to discuss the case load of that team. And the wait times were short for care. The quality of care was up. The management of our medications were the best that we had seen within the va. However, after 12 months, the team began to dissipate and what i was told and have been told since by dr. Steve hunt and others within the va is that this was a temporarily funded program and it was too costly to provide this level of care to exclusively post 9 11 va or veterans within the va center when a facility director has to provide care for all veterans to set aside the amount of funding that it required to provide this level of care for only one portion of that population was not practical. Mr. And mrs. Somers, i would like for you to elaborate, if you would, a little bit on the fact that you talked about daniel having enumerable problems with va staff being uncaring, insensitive and adversarial. Saying literally no one at the facility advocated for him. Could you give us any specific examples or are they generic examples . Absolutely. Probably the most i dont make it through this, howard will finish. Probably the most egregious event was when daniel presented to their er it took daniel a lot to go to the va facility and some of the things that had been mentioned here were part and parcel of the fact. Even along the highway in phoenix, there were speed traps on the highway, and when the lights flashed, that would give him flashbacks, even if he wasnt the one speeding. If he was going by on the highway at the time. So it was very difficult for him to drive down to the va. It is busy. But he presented there in crisis. He presented to one of the departments, to the Mental Health department. He said he needed to be admitted to the hospital. This is something that we have been told by his wife, who as jean mentioned, has a bs in nursing and his motherinlaw who is a psychiatrist. And he told them this on multiple occasions. So he was told that the Mental Health department they had no beds, and he was told by the same department that there were no beds in the emergency department. So this brings up another few issues, but the fact is that he went into the corner, he was he laid down on the floor, he was crying. There was no effort made to see if he could be admitted to another facility, there are two Major Medical centers within a mile and a half of the phoenix va. The vision issue is another issue that we need to discuss at some point. But he was told that you can stay here and when you feel better, you can drive yourself home. That is just an example of the lack of advocacy, the lack of compassion, that we know that not only daniel has encountered through the va system, we have met other veterans, specifically in oklahoma city, who had very, very similar circumstances at different vas. Do you know if he ever spoke to any va official about how he was treated . We do not. The other problem, of course, is that these visits are never the appointment system is so antiquated that things are not even documented. There is no way to go back into the system and to document a contact in the system. So no as far as were aware daniel did not speak to anybody at the va about this. It is just something he wouldnt do. He just wouldnt do. There was a feeling of, i tried and this is just another example of what the pressures that are brought to bear. We brought not only the vha, but the vba issues into account and these are just things that altogether just became overwhelming. My belief is that he still had that military mentality, you know, this is what an authority told you, i have to accept it. I cannot go above and beyond. I just need to accept what theyre telling me. Thank you. Mr. Michaud. Thank you very much, mr. Chairman. I want to thank the panel for coming today to talk about your stories and your family and really appreciate it, i know it cant be easy. So dr. Somers, my question is, can you go into further detail on about why you think it is important to encourage every veteran suffering with pts and other combatrelated Mental Health issues to supply a list of points of contact and get a hipaa waiver . Interesting that you should say hipaa because once somebody says hipaa, that sort of stops the conversation. We have been trying to deal with this issue because it takes a village, a large village, to not only treat but to recognize and to approach our veterans who might be in crisis. We feel it is critically important to expand what we call the support network, and actually at this point a hipaa change would be wonderful. We really we ran a medical practice and jean can tell you that what we have come to learn that what hipaa really says isnt what isnt how isnt how it is practiced. People are afraid of hipaa, so they take the regulation, that is actually there, and they take it to the nth degree and really you do have some options under hipaa, especially if you feel that somebody is a threat to himself or to his family or to the community where you can reach out to family members, or a caregiver in a situation like that. But we feel it is absolutely critical to identify prior to deployment, certainly during deployment, and after deployment what we call the support network, so that these people can be educated as to what experiences their loved one or maybe not even a loved one, maybe it is a High School Football coach or maybe it is your, you know, math teacher or maybe it is your best friend from the second grade, but so these people can be educated as to what the experiences might have been, what the signs and symptoms of crisis might be, and educate it to the fact that you dont take no for an answer. And if you see that somebody is in trouble, that you can direct them to the proper treatment, to the proper authority, to the proper medical facility. And thats not actually something that you have to worry about with hipaa. So thats one way that we feel that hipaa doesnt even come into the equation, hipaa would come into the equation when youre in treatment. And we really feel that if youre in treatment, and there is an issue, then the therapist should certainly take the opportunity to contact the closest people to the patient. Thank you. My second question relates to hipaa. I heard a case where even though it is the department of veterans administration, where vha employees could not talk of vba employees and they used the excuse of hipaa. Have you heard that have you had that problem . With your son . We havent heard that was a hipaa issue. We felt it was a total communication breakdown issue, the fact there was the Computer Systems werent compatible within the va system itself, and the fact that as far as we know phoenix still uses a postcard system for appointments, and nobody could document the fact that postcards were even sent. And we know for a fact that after daniel died, and the Suicide Prevention coordinator contacted his widow, and they were talking and they were going to send her some information as to what kind of counseling facilities were available for her, and she asked where are you going to send it, they, in their system, had an address that was four years old. And he had been involved with the vba and with the vha over that entire period of time. My time is quickly running out. Mr. And mrs. Selke, how long had clay been taking medication for his pts and how long has he was he denied medication through the va . He began taking medication in 2007, when he was back at Twenty Nine Palms recuperating from the gunshot wound in iraq. My understanding is that he, again, received medication that he needed when he was active duty. His care seemed to be good and he felt comfortable with it. When he transitioned to va care, he was never denied medication. What happened when he moved to houston, he was told that they could not refill his prescription, that had been that followed him from the l. A. Va and in Grand Junction, colorado, for a short time, he was having to start over as a new patient and i was had this reinforced yesterday in a meeting, but it was that was one of his major frustrations. And that ive heard from fellow veterans of his that when they go some to another facility, they have to go back through everything, all the recounting everything. And it that seems ridiculous to have to have that type of redundant system. When he was told in houston that he that they could not refill his prescription, he was told, you need to call the va that prescribed it, wrote the prescription earlier and see if they will refill it for you. He was leaving the country. He was going to haiti for a couple of weeks and he needed to have enough medication while he was gone. And clay was proactive enough and was able to do that. He just was determined and he said, okay, and he took care of it and he did get it from the Grand Junction va. When he came back from haiti, and went to his appointment in february, that was with a psychologist, a clinical psychologist, and my understanding was he was never he was not given a new prescription until he saw the psychiatrist on march 15th. So his first appointment was january 6th, second appointment february 10th or 11th, and finally march 15th, sees a psychiatrist. Also part of that issue was when he was active duty, lexapro was found to be the drug that worked best for him. Name brand drug, no generic, but they he had been on paxsill, on zoloft, a variety of drugs. Lexapro seemed to work the best with the least side effects. When he came out of active duty and into the va system, apparently generic drugs are the drugs of choice and he was given, i believe it is the generic for salexa, which is close, but not the same thing. At that time there was not a generic for lexapro. When he arrived at the houston va, and asked for a refill, and then he also somewhere in those first couple of appointments said that he would like to go back on lexapro, as that worked better for him, with less side effects, when he met with the psychiatrist, he said, okay, i understand from your background that thats worked before, and he did give him a prescription for lexapro. So clay leaves on march 15th, the psychiatrist office, goes downstairs to the pharmacy at the va, to fill his prescriptions. And he spent two hours in the pharmacy, he was called up to the pharmacy desk to pick up his prescriptions, and given the ambien for sleep, and given told they could not give him lexapro, they dont stock it because it is not a generic, that it will have to be mailed to him. So it was mailed to him, sometime within the next week, i think they told him a week to ten days that he would get this. A couple of issues there, if you know about antidepressant, antianxieties medications, you cant you cant stop them cold. You cant wait for it to come in the mail, and then expect that it is going to work quickly, it takes a while for these to work. They have to stay built up in your system. He was extremely frustrated. He called me as i said in my testimony on the way home and said i just cant go back there. The doctor at the houston va, i have spoken with him several times since clays death, hes been very forth coming. I appreciate very much the information that hes given me. Something in our last conversation which was just a couple of weeks ago that i had not heard before, i have been concerned about ambien, there have been just a lot of conversations among parents and spouses and family members of veterans who are dhave died of suicide and they have been on m ambien for sleep problems. Whether there is a connection or not, i dont know. But it was a high number that are given that when they have sleep problems and sleep problems are common, huge problem with post Traumatic Stress. The doctor, the other day, in talking about specifically ambien and sleep medications, he said, well, actually, ambien would not be the best drug for the type of sleep problems, and i believe the term is hyperarousal, but im not 100 sure on that, for the type of sleep problems that come from post Traumatic Stress. The nightmares and flashbacks and that sort of thing. There is another drug that starts with a p, i dont have it with me, like prazasin and he said that is the drug that actually works best for that type of sleep difficulty. And i was so stunned that i couldnt ask the question, well, why didnt you prescribe that drug for him as opposed to ambien that he was given over and over different times before. So that haunts thats something that haunted us for three years, because in that twoweek window, something went wrong. Clay had moved back home, he had just returned from haiti, doing volunteer work, which gave him great just great hope, that was great therapy for him. He had started a job. He had bought a truck the friday before. He called me and asked me to meet him and he bought a truck for work. And by thursday the next week he was dead. We were with him over the weekend on that saturday. The whole family at various points during the day, saw him. He had lunch with his dad. He had we went to a movie. Richard and i went to a movie with him that evening. I could i just i just couldnt believe it, that within five days he was dead. So we know he suffered post Traumatic Stress, we know he was treated for it, he was very open about it, sought help, and that twoweek window is just a mystery that haunts us. And we have done everything we can to try to find out answers. Mr. Lamborn for five minutes. I want to thank you all for being here. Youve given so much. I thank you i know the Committee Thanks you. And the country thanks you. I want to ask about the role of families in treatment and therapy. I have a constituent who came to me and her husband was stationed with the tenth special forces at fort carson, colorado, where i represent. And he took his life. Andan advocate for a program that has a holistic approach that involves families, whether parents or spouses. And i would like to ask any one of you who has insight as to whether there should be more of a role for families in the treatment programs that are offered through the va. Or is there a lack there . We certainly, during the time that daniel was with the va, certainly feel that there is a there was a lack. And, again, we feel it has a lot to do with fear of repercussions under the hipaa law. And also a total misunderstanding of what the law currently is. And i would like to take your point further and say that it shouldnt just be family, i think we would all like to say we did not have dysfunctional families, but there are dysfunctional families out there and so we started using the term support network. A lot of young men and women undoubt ledly join the service get away from families. That doesnt mean they dont have a support network. We would like to get away from the whole blood kinship and say it is a support network. I think it goes without saying, i recently read a report by National Association Mental Illness that there is no question that Family Involvement is beneficial. There is just no question. It becomes more of an issue, i believe, and it is why howard an i have been trying to work with the dod to get them to identify a support network, because certainly in daniels case, daniel was a geek. But he was at his absolute healthiest, mentally and physically after he joined the army. And he went through basic training. He was in great shape. If they have could have identified right then and said, daniel, give us a support network for you, who would you write down, you know . He had really, really good friends, we hope we would have been on it, his wife would have been on it, his motherinlaw probably would have been on it, his brotherinlaw. It would have been so helpful to have that list then. Because when he got back home, he wasnt capable of that anymore. I like to say, you know, not from a legal standpoint, but he had diminished capacity. He was not making correct decisions. Okay, okay. Anyone else . Mr. Selke . Thank you. Our experience, like most probably a lot of families is we didnt know what pts was. We had no idea. Clay was, again, very open about it. Told us he was destinationed with it. Told us he was on medication, seeking counseling. But we didnt know the ramifications of that. And like most of our warriors, theyre strong. And so he was, you know, put on a real good act. Had we known the extent of even what he talked to his counselors about, the idea that the somers have approached about regardless of the hipaa, you know, legalities of that, for if in fact somebody has that conversation with their that counselor, somebody outside of that counselor and the patient needs to know that the patient could identify somebody who would then be able to be aware of what is going on, and to say, you know, this person needs help. Clay, looking back, there was all kinds of things going on in his life. There were just red flags. And we didnt know. And there is a lot of literature out there, there is a lot of information. I believe that any family who has an individual involved in the military, after they had come back, or really anytime, they should probably just assume that there may be some sort of pts involved there. The suicide deal, clay actually had a conversation with susan and said, hey, mom, i thought about it, but i would never do that to you all. He actually addressed the issue and lied about it to us. And so the family plays a huge part in really being advocates for the individual and being able to just watch and watch for signs and then maybe be able to do something about it. In conclusion, i would have to say, the va needs to learn best practices and have programs available that include families. Everywhere. If i could add something to that, going back through clays medical records, for whatever reason, when he died, i immediately wanted his medical records. I wanted to Read Everything i could and try to grasp what was going on. He had apparently as early as november or december of 2009 spoken to someone in the va in the l. A. Va about suicidal thoughts, thats on one of his reports, at the end of 2009. He had separated from the marines at the end of april of 2009. I knew nothing of that. We didnt learn until the fall of 2010 when he told us, he said, i have struggled with this thought, but i could never do that to you all. I just cant. And i dont think i think in his mind he believed im thinking these thoughts, but i could never do that. As far as we know there were two times during the fall of 2010 that he did have enough serious suicidal thoughts that he did reach out, one time he called and talked with me, and another time he spoke with a close friend, and then after that second time he shared with me, you know, that or with all of us. So we knew in 2010 at the end of the year, we knew he had struggled with suicidal thoughts. And we also knew that he was on medication and were assuming that with post Traumatic Stress and suicidal thoughts and that that the va knew best how to take care of him. I begged him, please, lets go to private care. We will pay for it. We know great psychiatrists, counselors in houston, lets do that. He would not do that. He was adamant. He said, i have served in the marine corps for four years, my medical care is to come from the va, they owe that to me, i dont want to go to private care. I want to talk to someone who has either been in war or knows about war and post Traumatic Stress and the things that i have seen and done in are war. I dont want to go to private care. And that was just his personal feeling. We have heard that from other veterans as well. Thats as difficult as the system is, thats their comfort zone. And they need to be feel they can be taken care of. My hearts go out to you. Mr. Takano, youre recognized for five minutes. Thank you, mr. Chairman. It is very difficult to listen to your story. Im very touched by them. So i definitely want to thank all of the families for being here today. So, let me ask this question of miss selke, i believe a lot of veterans have that same feeling and therefore i do believe that we have to, it is incumbent upon us to make sure that we get it right at every facility, because veterans are expecting that. They dont want to see this be be a burden to their families financially. I am very much open to making it easier for nonva care to be available. And with that i want to ask dr. Somers, you are also a medical doctor, dr. Sommer esom . Im a urologist. Youre from the phoenix area. I practice in phoenix. We currently live in san diego. In san diego. Im from riverside, north of san diego, as you know. I went to visit my own va, in loma linda. Theyre able to they get theyre able to get veterans to see a family practitioner in 24 hours if need be. Im not so sure about Mental Health care or psychiatrists. They indicated to me there is a shortage of psychiatrists. And i recently visited a new kaiser facility and i asked him if there was a what shortages he was experiencing. Can you tell me if there are general shortages in your area of these kind of practitioners . There is a shortage of Mental Health professionals nationwide. And there are many issues that go into it. Certainly reimbursement is one. We know one of the people that daniel had been seeing because and this is another issue of continuity of care, he was forced to go outside the va system, just because he couldnt be seen in phoenix. There was just no availability, no Mental Health available. And i think you have to divide psychiatry and psychology. For these people suffering from ptsd, it is the psychologist and the psychiatric social workers who are providing most of the care as opposed to the psychiatrist themselves. But psychiatry and psychology are incredibly important and what happens is if we try to recruit into the va, the community is losing that Mental Health component. And it is a huge issue. It is an issue that has to be addressed by our medical schools, by society in general. But it is not just an issue here and there. Here is the thing. Dina titus and i represent a bill that would increase the number of residencies at va hospitals. I expect a number of those if we approve it, a number of those residents would stay, but also something would go into the community as well. Right. My thing is even if we do approve make it more easy, easier for vets to use, that areas like mine, theyre still going to have trouble finding that care, you know, in the community. They will. And theyll have trouble even if you have people in the community, youll have trouble finding people in the Community Aware of military culture and who are aware of the issues that veterans face, and, again, thats just brings up a whole other issue, whole other series of issues. I wish i had more time. Maybe i could get your information through my staff, because im trying to understand also your criticism of the vista medical records. There is also an issue of the be trying to with the pc3 program and with the other issues that are being promulgated now, there has to be communication between the va and the providers who are seen the veterans being referred out. So huge, huge issues that have to be addressed. I think i understand your point of view as well about your doubts about radically restructuring, that we got to try to get it right in the va facilities because of that expectation that miss selke and the selkes son had, that they that was their comfort zone. So we got to do both things at once, make sure that every va center has excellent Mental Health care and try to provide some options. Yes, sir. My concern with the bill that just increases the number of practitioners at a hospital, were not solving the issue with effectiveness of care. So it really has to be a systematic approach to solve the efficacy of what care is being provided as well as the numbers to accommodate the sheer overwhelming amount of veterans that are trying to access that already broken system. I just wanted to add that, sir. Thank you. Mr. Chairman . Dr. Roe, youre recognized for five minutes. Thank you, mr. Chairman. And i thank, as a father of three, and a veteran, i appreciate your courage to come here today and speak. It is a really heart warming and i know this is very difficult for you to do. And it has been difficult to sit and listen to the testimony. There are a good number of veterans sitting up here. Im a veteran of vietnam era. And just want to thank you for that. And in being here. I can tell you this past weekend, i returned to something very joyous for me. It was a reunion of a bunch of young boys growing up in the 60s, who were all eagle scouts. And all but one was there, of our friends, he didnt make it out of vietnam. So i can tell you that this loss that you have, that youre sharing with us, is very, very helpful, that loss will go with you as it does for my friend of almost 50 years. So thank you for your courage to be here. I know it is very difficult. And sergeant renschler, you bring up a great point, all of you have today, and the coordinated effort you brought forward, that Team Approach i think was very good. And i certainly do understand what the va was saying, if this works for the oif, oef veterans, it should work for all veterans. The majority that theyre serving are veterans of my age. I think this needs to be expanded if that method that you put forward, it looks like it worked extremely well, should be looked at. And dr. And mrs. Somers brings up an incredible point. Dr. Somers, you probably dealt with, as i did, some primary care in your practice when you were in urology. You dont just get to be a urologist, your patients get to know you and share a lot of things with you. And dealing with this is very complicated. As you all have pointed out, and miss selke so eloquently pointed out, is that it this approach of caring for people with pts or chronic Mental Illness is extremely difficult. Dr. Somers and i could go in operating room and remove a tumor. Thats easy. This is much more difficult to do. And those signs and symptoms are very difficult to spot because miss selke, you saw your son, when he was actually, you thought, doing very well, that week before he passed, and i think as a doctor, thats been one of the things that troubled me all of my career, is trying to figure out when you have a patient that would take their life, it is why did this happen, and many times that week or two before, things seem to be going well. You think things are going better. I think dr. Somers, you and your wife brought up something that is extremely important, that a good friend is probably as important as a good doctor, good person to lean on. And i think you have to do what sergeant renschler was talking about to have this very Sophisticated Team together for people in need, but you also just need someone, it may not be a family member, like you pointed, it could be a coach or pastor or whom ever it might be in your life, it could be a family member, i think putting all that together is a real challenge. I will hear later from the va about what they plan to do. But any further thoughts along that line would be helpful, if anybody would like to share some of the your thoughts about what we could do. I think it is important for the transition program. I know before that brian went to iraq the first tour, he went to california where they have a base where they teach them all, like, they make it like an iraqi town. So they learn how to control crowds, take buildings and all that. But had th but when they come back, it is boom, youre there for a week and then out in the community. There is no transition. Why cant they use those centers they use to send them where they could have psychiatrists, psychologists, and look at them, give them assignments, see if anybody has poor concentration, poor memory, you know, and use these resources that we have, you know, say, okay, now you need to go do laundry, give them a list of things to do see if theyre able to do that, and, you know, observe them, we cant just take them like cattle and put them up through a bunch of questions and then let them go in the community where they dont have their brothers to confide in. When they come back, they have put their life on the line to trust these other brothers, they would die for them. They come home, they dont have anybody theyre going to trust that much. And nobody that has been in war is going to understand so they dont open up. The most people that open up to is their brothers. Michigan has a program called buddy to buddy. That they put together one veteran, you know, that has been home with the veteran. So that if they have any problems, that are going to open up to that person much more than they are a therapist. Or have Group Therapy, let the veterans talk among themselves. They could, you know, have a group of ten veterans and then have Group Therapy and maybe they could confide in each other. Because it is going to take a while to build up trust with a therapist, if you do. Totally agree, thank you very much for your courage of being here today, mr. Chairman. I yield back. Mr. Brownly, youre recognized. Apologize, mrs. Kirkpatrick, youre recognized. I appreciate what you said about once a diagnosis is made, and medication is prescribed, staying on that, on that medication. And im really want to know how often our veterans have to refill the prescriptions, and i would like to hear from each of you what youve learned about that experience, are you given a 30day supply, they have to go back constantly back, or on sergeant, we can start with you and then work our way down the panel. Yes, maam. So at our facility in Washington State, medications are given on a 30day supply. There is an option for mail refills. The system is pretty confusing and i normally mess it up pretty well, so my wife has to manage that for me for most part. You have to be able to put in a request three weeks before you need it, and i usually forget until im about to run out and so then im off my meds for a long period of time, which is never good. As far as the other medication issues that have been discussed, continuity of medications from one facility to the next. Im in southern part of Washington State, and people who are coming up from portland, oregon, which is about an hour away, are on medications that are not transferrable to the va facility where im at. So they have to start all over as a guinea pig is what was discussed earlier, try medications they may have already tried in the past to get to the point where theyre able to approve a nonformulary medication. It took four years for the dod to balance nine medications for myself, and when we transitioned to va care, many of those medications were not on the f m formulary and we had to go back through the guinea pig phase again and we ended up with 14. There are many issues as we talk about that. That is just unbelievable. Any other families want to brian was never put on medication. They diagnosed he had depression, pts, but never put on any medication, he was put on medication for his back when he was thrown from the humvee, naparcin and muscle relaxer and that was temporary, but they never even prescribed, screaming out three times a week with nightmares and having your brothers wake you up and then telling the therapist how embarrassing that was, i think you need to be on some medication. Agreed. These medications are so subtle, and theyre so particular to the individual. It is just mind boggling that there is not an easy way to identify and work with the individual vet, determine exactly what that cocktail, if you will, looks like. And then be be able to without to just seamlessly transfer that to wherever that bed is. These people are young and theyre on the move. And, you know, theyre all over the place. And so that those barriers need to be taken down. Dr. And mrs. Somers. Yes. Thank you. And thank you, representative kirkpatrick, for being such a support and a help for us. There is multiple issues that have to do with the medications. Just the fact that the formularies are not the same is a huge issue. And it doesnt just affect veterans at the va system. There are veterans who are retired from the military who see both who see physicians both at the va and the dod. So they are seeing people at both different medical centers and they cannot be on similar medications from one to the other because the formularies are not the same. The problem is that not only does the va use 99 generics, but they use the cheapest generics. So daniel, who had not only ptsd and tbi, but full blown gulf war syndrome, which included irritable bowel, had only certain medications he could tolerate. Maybe the chemical in the medication is the same, but the bonding agent is different. Maybe hes on a medication he only has to take once or twice a day, but the va gets a better price, so now he has to take it three or four times a day. And the change in the medication changes everything. So i mean the issues, the issues are just huge. It is not only that and the other thing that we have heard, and from unimpeachable sources, is that vas vary as we heard with their pharmacy policies. There are some vas where you can go and get a brand name medication with no problem, other vas that essentially it is impossible to get a brand name medication. So, i mean, that brings up this huge issue that we have is why there is so much variation in the entire system. Why we cant have more uniformity within the va system as a whole. Thank you. Thank you, dr. Somers. My time is up, thank you. Sorry. Let me just conclude by saying your testimony is heart breaking. And i can barely hold back my tears and i thank you for being here. I yield back. Thank you, mr. Runyan, youre recognized for five minutes. Thank you, mr. Chairman. And i thank all of you for sharing your stories and truly being great americans and great patriots because your stories are going to help people in the future and thank you for all that. A couple of points and i think dr. Somers was talking about it, and i think we see it all day. We talked about this in the hearing the other night. It almost seems like the va is so fragmented, that there is no overwhelming mission from the top with flexibility below. Thats and i think there is a structural breakdown on how youre actually going to conduct business. And thats really where were at, whether youre talking vha or vba. It is the same issue. And we have yet to i think next week were digging into some of the vba issues also. Its a culture. And one other point, and then ill ask one question, and it and miss somers was talking about it and dr. Roe also validated it, when you talk about community and talk about support networks, these men and women are spending more time away from the Health Care Facility than they are in the Health Care Facility. So friends, family members, you know, classmates, buddies, all have to be part of the healing process. Not doing that. And i know the term wholistic has come up a few times. I think the sergeant mentioned it a couple of times. It is part of the healing process. There is no Silver Bullet to cure somebody. You got to be able to help them in many different ways. That being said, in the vas testimony, they mentioned Suicide Prevention coordinators are supposedly placed at all Va Medical Centers and the large clinics. Theyre supposed to follow up with veterans at high risk. Were any of your sons ever contacted in that first month after they were designated high risk by a va Suicide Prevention coordinator . Were not aware of that. The fact they didnt even know where he lived would bear proof of that. Thats one of the issues that were dealing with also and that goes into the whole support network issue, is that and we have spoken to so many, so many families in the same situation is that daniel was married. And that basically shut us out of the equation. And thats where if we had the opportunity, if we could do some changes in this misinterpreted hipaa regulation where we could have been more in touch with his therapist and they would have felt free to talk to us, where we feel that we could have been more help. But since he was married, it was as if we didnt exist. I think thats important point is, like, when brian was injured in the tank explosion, i was notified, 3 00 in the morning an they called me from fort hood saying he was injured, where they had taken him, hes back with his unit, but yet you diagnose somebody with ptsd and tbi which can be life threatening injuries and nobody notifies you. That just doesnt make sense to me. Anyone else . Your point, or question of being flagged as a high risk, this is something that came up that really baffled us, i guess. When clay was transitioning or moving to houston and started to go to the va in houston, his records apparently from what i was told, those records were not seamlessly, electronically sent. They did not have his records from l. A. And thats where the bulk of his time was once he had gotten out of the marines. So as i look back through those medical records, as i said, there were at least two or three times in there that it talked about and he talks and admits to having had suicidal thoughts, so i assume that he was flagged, would have been flagged as a high risk. I mean, it says on the medical record, high risk, highlighted. When he comes to houston va, nobody knows hes a high risk. The psychiatrist didnt have anything other than clay saying, this is what my past history has been, and this is the medication ive been on. So thats a great point is to when are they flagged as a high risk . Do any family members know that . The only way i ever knew that anybody called him a high risk was when i got his medical records and poured over them after he had died. Thank you. Chairman, i yield back. Miss brownley, youre recognized for five minutes. Thank you, mr. Chairman. I want to join my colleagues in thanking all of you for being here, and sharing your stories and certainly through your stories about your sons, it certainly, to me, i feel their patriotism through your stories and their overall most sincere risk commitment and service to our country. So thank you for being here. I wanted to ask sergeant renschler a question. And so in your service, when you were in theater, was there any support system in place for you to go to get any kind of, you know, Mental Health support while you were there. Hearing brians story, it was re gut wrenching to hear it, and, you know, just to wonder if brian had a place to go to, why he was in theater, how helpful that might have been in terms of his time there, and his transition coming home. Maam, thank you. When i deployed was 2003, it was right after the initial surge, it was a completely different war theater. We really didnt have anything set and established at that time. So to answer the question, no, there wasnt anything. However, again, i work with many, many veterans, currently, in active duty members and i have been told in recent deployments in afghanistan that after major events take place, there is sometimes availability to have a type of crisis debrief. It is somewhat available. It is not it is not streamlined, not across the board, but it has been implemented on some level. If i may, the problem is that we know that there is an effort in the dod to destigmatize Mental Health issues. But if youre in theater, i would venture to guess that it is going to be incredibly rare for somebody to take advantage of that because all of a sudden theyre going to be taken off duty. And the whole idea to destigmatize it is to say, okay, you come in for treatment, but then once youre better, then youll be able to rejoin your unit or youll be able to regain your security clearance. But while youre under treatment, youre not with your unit, and you lost your security clearance. So i mean the issue is a huge issue. And we know from people that we have spoken to that the people at the top are aware of this, and theyre trying to deal with it, but there is just so much you can do on a boots on the ground level. Well, if i may, so there is two separate levels here. There is a crisis response, muc type of a situation. If you experience this, find somebody to talk to. More of an education and immediate response. That has been available as stated, most military Service Members and veterans as i stated earlier in my testimony are not going to say, gee, that was a horrible experience, i should talk to somebody before i have issues. They are going to wait for it become a crisis point before they seek treatment. I just feel like if it was part of the culture being in theater that there is kind of constant dialogue that is going on, that that would have to be helpful to the men and women who are are there. Brian did tell me one time when they were on the 15month tour there was at one time they lost four people in one mission. When he was out there, the morale was very low after that because these were people high up, sergeants and lt and that. So they sent someone in, and when the soldiers would go in and talk with them, he asked the same question, was it sort of like a movie . That just insulted them almost. It was like, why would you ask such a silly question, so they all shut down. I think by not processing those thoughts you are going to internalize them so they are never dealt with. I think even before they are in theater, i think in basic training they should be taught ptsd and while they are deployed and report on each other for their own good and in transitioning home. I dont think we can say it enough. Thats my opinion on it. Thank you. Thank you. I think it just confirms we prepare our men and women to go to serve and to go to war. We dont prepare them very well to transition back. Dr. Somers, you talked about hipa and the barriers to hipa. You mentioned also modern technology . Am i . I yield back. I apologize. Thank you very much. Thanks to the moms and dads and sergeants for your testimony. I will look forward to asking the va question. I yield back. Thank you very much. Thank you, mr. Chairman and thank you to all the families being with us today. For many of us sitting here today, the pain is to recognize your commitment to give meaning to your sons lives. Im the mother of two sons 22 and 25. I cant fathom what you are going through. I want you to know we will do our part to give meaning to their lives. It makes me feel, personally, im becoming more and more antiwar proveteran. I think our country had those priorities misplaced getting us into conflict, but not being focused on the cost, societal cost to our country and to the population. These extraordinary young men and the promise that they held going to haiti and making a difference right here. I want to focus in because i think from your experience you can really help the va and the dod to understand what could make a difference. I want to commend you all with the specificity of your recommendations. In particular, ive been trying to understand best practices, and whether there is any effort or known groups or the types of medications that are helpful, have any of you in any of your discussions, whether within the va or since then, the experience you had meeting with people, have any of you come across any effort to share best practices with the transition, particularly around pts and tbi and just the trauma, how we can help people coming back from this level of trauma . Maybe we can start with the sergeant, if youre aware of any types of programs that are effective. Thank you, maam. There are great things that are effective, but the problem is is even though we can Group Veterans together in a large sum and combat veterans in another category, its hard to label one program as effective for all. So many find Group Therapy programming very successful. Many find combat veteran support groups very helpful. Some find oneonone peer mentoring very effective and helpful. This is why when we are talking about evidencebased therapies, best practice of the va pushing pct, these things can be deemed as best practices, but many veterans arent ready to go through such intensive therapy. They would rather pace themselves. Though they can be very effective squashing the problem, i cant say there is one thing that is straight across the board going to work for everybody. Thats why i stress the importance of a team that works together to bring together whats best for each individual veteran in a veterancentered care rather than a systemic care a veteran has to adhere to. You are looking for an individualized approach, but a Team Approach. You mentioned others on the team may see something in the care. Yes, maam. I also want to visit this issue of hipa. Im an attorney. I worked 25 years in health care. Theres definitely a waiver process. This happens in private sector medicine. Are any of you aware, and through your review of the records after the fact, have any of you experienced the va asking the patient at any point in their service for a waiver to identify people that they would be willing to have their medical record shared with . I know we had specific daniel ended up going outside the va because his psychiatrist retired and they said we dont have anybody for you to see. At the time he was having suicidal thoughts. His motherinlaw who is a private sector psychiatrist referred him to somebody she knew in the community. As she was seeing that person, we asked him, can we be a part of what is happening and he said he would ask her, but my guess is that he never asked her and we never got the feedback. It was embarrassing is probably the closest word we could come to with him to share that information. I can speak to that a little bit, as well. Going through clays medical records from houston from the va, there was a form in that assessment and there is a question that says, do you want us to or will you allow us to, or it said do you want your family to be contacted regarding your care . And he had checked no. As difficult as that was to read, i know him and i cant even imagine, and i really i just cant even imagine. These people are so strong in the first place to raise their hands and say ill go. And they go to war and they have these injuries, and especially with the mental injuries. Its so difficult to feel that you are a burden on other people. I know clay felt that, even though he knew how much he was loved, unconditionally. Any of us would do anything to help him, but he was 28 years old. He had been a marine scout sniper. You just want to be able to take care of yourself and get the medical care you need. So it didnt surprise me to see that, that there was a question of would you allow your family. Thank you. My time is up. Thank you, mr. Chair. I yield back. Thank you. Mr. Kaufman, you are recognized for five minutes. Thank you, mr. Chairman. First of all, thank you so much for the service of your sons and sergeant, in your case your own service. My heart goes out to you for your losses as a veteran myself. The question i have is, i mean, do you think, certainly sergeant in your case and then for the parents in the cases of your sons, was va overmedicating them in lieu of giving them therapy . Thank you for that question. This is an issue we battle with on a daily basis as we provide support and service to veterans and active dut