thank you very much for having me i have spent thirty five years researching and writing about health care in the private sector about nursing patient safety in teamwork and six years writing and researching the country and i think privatization would be a disaster for veterans and a disaster for all americans because the b h a doesn't just serve a veterans it serves all of us i think that the v a should be considered a model of how care could be delivered if we had a rational health care system in america i think i am a strong supporter of some form of nationally supported health care system like exist in every other industrialized country except our own i think that actually the slogan should be v a care for all not medicare for all because the viet medicare is a payer not a system and the v a is a payer and a provider which is why it has the outcomes that it has i think the v a i've spent six years sitting in v a hospitals facilities rehab hospitals blind rehab centers p t s d programs traumatic great i mean you name it it's huge system obviously i couldn't be everywhere everywhere it's got a seven hundred sites of care one hundred seventy medical centers there's so many medical centers at the v a can't sometimes even keep track of how many medical matters there are  i think the model teamwork safety quality coordination and integration of care are what we should all experience in our health care and what we sadly don't and i think that if we do have a  which i hope we will eventually get i think if we ever do have some sort of medicare for all single payer health care system where provision and insurance are are joined i think that the v a should be imbedded in that system not replace by it because as long as we continue to have these terrible wars which in my view are terribly misguided and necessary and we keep producing all these wounded warriors and by the way you don't have to be a wounded veteran to have to have you don't have to have been in combat to have been a wounded veteran i mean many veterans suffer all kinds of exposures just never having left the continental united states and we have to take care of those occupational injuries so i believe that we must have the v a be part of that system and we could eliminate a lot of the stupid eligibility requires that we see requirements  that pit veteran against veteran citizen against citizen and that really don't serve the needs of veterans or all americans i think that after having experienced  health care as a patient but as an observer i know and i can say this with utter conviction that i who have the best health insurance in the country i can go anywhere i want practically to anyone i want i will never get the kind of care veterans get at the v a when it's at its best because it just doesn't exist in the private sector health care system if you have care at the b h a for patients who are cherry picked because they are older sicker and poorer right that i cannot take you as a patient if you are healthier and wealthier you're not eligible you're not in in a top priority group and they have they deliver this care this integrated care  at a much lower cost and higher quality than is available in the private sector i think that the v a s model of integrated coordinated care can only cannot exist in the private sector the way the private sector is currently constructed and that is because no matter how well intentioned its individual providers it is our private sector u s health care system is profit driven not mission driven  it is lord it is fragmented not coordinated and it's largely organized around the provision of disconnected episodic medical procedures and treatments that's why we have the highest health care costs in the industrialized world  and why so many patients die from unnecessary preventable medical errors and injury i think that the v a health care system that one some of the things you have to know about it are on the sheets but it is fully integrated integrates mental health and primary health care it has one of the best electronic medical records in the country even in the world which care of our veterans and veterans have fair specific health care issues they have more chronic pain more suicidality more mental and behavioral health problems more homelessness etc than the average patient in the private sector the average sixty five year old patient the private sector has three to five co morbidities are presenting problems the average vietnam that has nine to twelve when we consider the question of privatization and make no mistake about it under this current mission act that is being implemented now more and more care of veterans will be outsourced to the private sector and that is incremental privatization even though the v secretary denies that what they are doing is privatization when we consider the question of privatization of whether privatization is a good idea those of you in the room who think it is a good idea i implore you to think about several questions one is is the private sector capable of absorbing more than nine million complex veteran patients and serving their needs is it capable of delivering timely high quality care i believe that any reasonable analysis of the current conditions will lead people to say resoundingly no we have a serious problem in our country with primary shortages of primary care physicians we need something like forty five thousand more by twenty thirty and our medical schools and residency programs aren't aren't producing them fifty five percent of all counties in the united states have no psychiatry or psychologist or social worker where our veterans going to get care in those counties all of which are world ninety two row hospitals of closed in the last decade and seven hundred are expected to close in the next decade where our veterans who live in rural areas many of them do live in areas where areas going to get care we have a horrible crisis of preventable medical injuries and errors can i read my lad the paragraph or one paragraph ok so i just want to quote from a v a report supporting the dangerous access standards being currently promulgated by the v secretary and his cult brother and industry funded advisors the report states that v a wait times and care regularly outperform the private sector did and that veterans prefer to get their care at the b h a if this is the conclusion of proponents of outsourcing more and more better and care to the private sector of starving the v a of resources of refusing to fill forty thousand forty three thousand vacancies of the b h a we have to ask what is going on and i think the only logical can answer to that question is that we are seeing the push for privatization of the v a chase system not improving and strengthening the system because of an anti government radical libertarian idiology driving this movement and because of the financial interests of some of the private sector health care industry that is interesting cat in capturing the v a pot of gold i believe our decisions need to be made on the needs of veterans and the rest of the patients like you and me that the v a chase serves and i don't think that is what happened in what is happening today thank you thank sector could learn from that could serve as an example for private sector health care the quality in the v a no matter kind of how you slice and dice and look at it whether it's patient safety the hugest metrics that people follow around prevention and chronic disease management the v a is as good or better than privates sector and v a has done that for a long time and private sector has actually caught up parts of private sector have caught up with the v a s performance and the v a does that i would contend at a lower cost structure than medicare particularly when you kind of look at the population served by the v a versus medicare and kind of the difference in benefits covered by the v a versus by medicare then in general commercial side of private sector health care is much more expensive than medicare  focuses really i think outstandingly well on proof on prevention and ambulatory services has extraordinary capabilities for mental health which is usually sorely lacking in private sector and really i think coordinates care across the entire continuum and those are things i think that the v a does does very very well i think it does that in part because the economic incentives within the organization are really aligned there's a culture of stewardship to manage affordability that exists within the organization they can negotiate drug prices which private sector health care generally cannot do optically medicare cannot do and and we really the v a follows evidence based medicine around formulary supply chain management and other things like that and particularly i think in partnership with v b a can address some of the health the term minutes of disease homelessness food insecurity they have you know job training and that kind of thing addiction  therapy program so i think there is much that can be learned i think i often compare the v a to kaiser permanente because they should those two organizations share a lot of d n a i think in common there are things the v a doesn't do very well that i think private sector would be foolish to try and replicate you know if you look at the kind of word salad that was up here at the beginning it is big it can be anonymous and impersonal in many ways there are a lot of regulations and rules that are hard for veterans to understand and quite frankly hard for staff to understand and deliver you know explain those things in a consistent way across the country there's three hundred fifty thousand employees in the veterans health administration so i think there are some really good things that can be used as examples but for me there's a but at the end the follow up that and the reality i think for the v a is that the veteran population which is currently at about twenty million veterans in this country is expected the v a predicts that that population will decline by about thirty percent over the next fifteen to sixteen years  vietnam war was really the last war that was fought with kind of full time a regular active duty military personnel since then wars have been fought with guard troops particularly if you look at world war two but even vietnam people came back and left the military and stayed in places where they they left the parted from military service and so they were concentrated particularly in cities like l a seattle  today those guard troops come back and they go back into every county in the united states and so you know for that reason accessibility has become a major problem  over the last ten ten to fifteen years particularly for the v a a geographical accessibility problem and then there is a timeliness of access issue and i think that i would contend i work in private sector now there are those same access issues in private sector if you look at the appointment data you can get an appointment today in the v a pretty comparable to private sector but there are delays and access issues i think around acute care and around specialty care so you might get in to see your orthopedic surgeon for a visit in a timely way but you might wait a long time to get your hip replacement done if it's an elective  procedure so i think the other point i would just make is if you look at the v a infrastructure it's old some of the v a hospitals were built in the early one nine hundred six the cost of building a new v a hospital in denver was almost two billion dollars just tell you a short story in that when i was working in central office we wanted to  centralize calls to call centers much like kaiser does when you call a kaiser clinic you're actually talking to somebody in a call center to schedule an appointment door i'm get a drug refill it's cetera and we had a contractor look at helping us do that and they came back and said you have a problem because your phones are still on p b x systems are not digital and i said ok well what's it cost to fix that the answer is just to bring the phone systems in the v digital standards what it cost three billion dollars i don't see american taxpayers investing in the v a infrastructure to maintain that and i think that you kind of marry all that up declining veteran population people in every county really aging infrastructure that's not a formula for success in my mind and i think that you know i would say i don't know that the v a is going to be privatized we could debate that that's probably why we're here tonight but i would predict that the v a or the future is not going to be the v a of the past good evening i have the great pleasure to speak this evening as a post nine eleven iraq war veteran and i hope my comments here do a service to my sisters and brothers both in the audience and those from recent wars i served from two thousand and one to two thousand and eleven as an army chaplain with time spent in the national guard in the reserves on active duty my veteran perspective is equally informed by my experiences as a patient here in  seattle v a from my vantage point the future of the v a is best answered by looking to the future of veterans themselves in september of two thousand and seventeen seven years after my deployment to iraq i was working at a local nonprofit not too far from here when the front office called me to sign for a delivery when i arrived i discovered that it was joe the delivery guy someone i had known bringing a tank of helium that the director had ordered so that we could blow up our own balloons for our monthly birthday celebrations joe then proceeded to explain how i needed to securely attached the tank to a concrete post just in case it tipped over and  became a projectile missile upon hearing this i slowly began to walk away from joe and the death trap that he had so cavalierly brought into the building noticing the color draining out of my face and my sudden stuttering of words joe offered to carry the helium tank himself to our basement storage area while i returned to my office visibly shaken by the grace of god one of my colleagues noticed my distress and offered to be the point of contact for all future whew helium deliveries for you see helium tanks look quite a bit like an i e d or a roadside bomb but i was never hit by one so i was surprised by my response but the soldiers in my unit were and the service members at the base hospital where i worked were and i buried some of them not all of us carry a debilitating fear of helium balloons but we do carry depression and anxiety in chronic pain and worn out knees and embedded shrapnel in toxic poisons and immune system problems mysterious cancers addiction guilt dissociation and sadness comprehensive veteran health care therefore is a no brainer but veterans do not exist in a bubble they exist as members of families and they have spouses and partners and children and parents and relatives and neighbors and friends and coworkers and all of these people need to be healthy for veterans to be healthy the individual tasks that we carry can range from tending to the physical and psychological implications of brain injuries we have to tend to absent limbs from roadside bombs we tend to p t s d from deathly encounters and we tend to an inexcusable suicide rate but there are other tasks collective ones that us veterans also manage in our daily lives but they are not ours alone to carry some of us have a spidey sense that works over time and is extremely perceptive at picking up disturbances in the force things that are out of place behavior that doesn't fit these veterans are the guardians of our public spaces there are others of us who can no longer bury our heads in the sand pretending that the day to day decisions of ordinary civilians have nothing to do with the wars we wage overseas these veterans are the guardians of our moral fiber and still for some of us our experiences have carved canyons of sorrow so deep in our soul that it would take many lifetimes to grieve it all these veterans are the guardians of life in a numb and distressed society and these are some of the most important tasks that we can tackle and every veteran i know is shouldering the weight of them in some kind of way which is why the question of privatization on the one hand and single payer on the other is best addressed by asking who exactly needs to be healthy for society to be healthy veterans need health care for veterans to be healthy the rest of society needs health care privatization has some similarities to contracting out and we are fifteen years into middle east wars where we contracted out logistics supply food water security and not to mention the other unsavory jobs that we paid to have done and this is not a position i would say of integrity or honor we should have three to four times the number of veterans from iraq and afghanistan that we do and veterans health care is not like a cup of coffee or the purchase of a car or a mortgage on a home instead it is a public good more like roads and water and schools things that need a high degree of integration and public support in order to work well on the other hand i'm also cautious about any endeavor which expands the federal government and i support the v a for all with both eyes open understanding that due diligence and accountability are essential parts of the equation i hung up my combat boots nine years ago i packed my uniform away and my salute is rusty but the chaplain in me lives on in my soldiers and their families need an integrated streamlined system i experience this at the v in ways that i did not experience in the private sector thank you thanks kelly ste also like to express my thanks for being here in addition to the roles they are and described that i had in the a that is serving as a be a primary care physician for thirty six years and directing a research center for almost twenty i had the fortune good fortune to have several other roles in v a i directed a primary care clinic and beginning in the days before it was actually legal to deliver primary care in the a i served in central office is the chief quality and performance officer as the chief of v a research and my last job as the director of analytics and business intelligence so i've had the opportunity to look at v a from a variety of perspectives and i as i answer this question about where the v a should go i can't help but look back at the history of the organization i think that's important to know and complements the notion of looking forward it's important to recognize that the government has provided health care to veterans directly following every war since the revolutionary war in the early years this was largely custodial care but following world war two the country made a commitment to improve its care of veterans and not only health care but also as jim mentioned provision of education and financial security through loans and pensions many i think have come to regard this as a covenant between country and in exchange for those who devoted years of their lives and often their lives themselves for the country and to meet this challenge shortly following world war two general mark bradley made  a in a two page memo a an agreement with the medical schools of this country to provide high quality care to veterans in exchange for educational opportunities to medical training  and ultimately as you all know the v a was converted into a cabinet department in the ninety's and since then however as jim alluded has been relatively static in terms of its  like so many large federal programs the v a s been a bit of an experiment there was no formula or example preceding it and i would submit to you that it's as you've heard been a very successful experiment furnished as we've heard high quality care to tens of millions of veterans over the last seventy years provided training to well over a million health care professionals along the way v a pioneered the electronic health record supported nobel winning nobel prize winning research and provided global leadership in caring for conditions like p t s d hypertension spinal cord injury  and chronic medical conditions and as also said this is been accomplished at a net cost lower than it would have been provided this service within the private sector i think often forgotten and not mentioned is the fact that the v a has provided employment and a sense of purpose to hundreds of thousands of americans who actually work in the v a i am one of those individuals most certainly and we could i'm sure in discussion will come up there even stumbles  deficiencies that have received vocal criticism but overall again i think this is been a very successful experiment and probably arguably as successful as any other large government program in this country  tens of thousands of lives have been improved and many saved and many believe including i'm sure as i gather from this audience that the da has demonstrated how a federally funded globally budgeted health care delivery system could work but i share some of the concerns that jim has outlined one the demographics of a declining veteran population to the outdated facilities with an average age approaching sixty years and maldistribution of those facilities which mirrors where veterans lived forty and fifty years ago when those facilities were built and not where they live now and complicated by the fact that the v a promises to deliver health care services to every veteran irrespective of where they reside no health insurance company would would would do that and it's difficult and those are three of the four big obstacles i see to v a and the largest which i'm surprised no one has mentioned so far is the erratic and inconsistent management by both the executive and legislative branches of our government which i think is the most serious problem facing the v a it's very difficult to operate perhaps the largest and most complicated health system in the nation in a highly politicized environment with increasing and changing mandates and as jim noted very little flexibility or capability for long term planning or budgeting based on these considerations i long expected that the v a would evolve over the next two to three decades probably shrinking to meet the changing needs of a diminishing number of veterans at this point however such essen sensible and gradual glide path seems unlikely to me if not impossible as essential resources are being shoveled out of the system faster then the systems can to track and manage them can be constructed my expectation at this point is that veterans will likely be can fused and disappointed when they experience difficulties in obtaining prompt and high quality services in the private sector that do not conform to their expectations and simultaneously an underfunded v a system will be forced to continually reduce services i do believe that the v a has demonstrated that it globally budgeted national health care system can function effectively as we've heard but what i think i have also learned is that unless it's insulated from the ever changing political whims it would be difficult if not impossible to operate efficiently and effectively even the national health service in britain which is operated as a national trust has had difficulty with politics interfering with the delivery of care but i'm somewhat pessimistic that we'll be able to do that but perhaps i'll be wrong you and reflect a lot of the statements that have been made long story short begin at the end and i think the v a should be maintained i think underfunding is an issue that is at the whim of really reactionary politics like many other things in our society and we have to decide as a society and an electorate really if we do feel that health care is a human right or is it a privilege only afforded to those who can pay even if you can pay top shelf insurance if you fall ill you lose your job you lose your job or employee supported health care and then you will become indigent as been shown in several studies by the harvard school of public health fifty one percent of american bank personal bankruptc filed because of health care expenditures of the people who filed for bankruptcy seventy five percent of them had health care coverage when they fell ill so we are all  slips mercy in this paper universe is the old song goes to our good luck and subsequent good health so there's a lot of things so i'm a health educator i'm a general surgeon i work at harbor view i've been there continuously since one thousand nine hundred one i was a student at the v a during medical school i worked at the v a as a resident and so i see that from that perspective and also for the perspective down the street at what is probably one of the last remaining other vestiges of public health institutions in our inner in our city which is harbor view and i can tell you that i think the v a is very well organized as susan has pointed out very well in her book and i would if you haven't read it i would highly recommend it it is truly an in depth analysis of the v a and all that it is done in terms of its not just delivery of care both inpatient and outpatient but more importantly to the growing need of the psychosocial aspects of health care particularly p t s d and other things i can take somebody gallbladder out my colleague can bypass there are blocked artery but the tough work in the heavy lifting is taking care of people with p t s d addiction and other emotional issues and i don't know about any of you but even those of us with top shelf health insurance who have tried to access mental health care it's nearly impossible nearly impossible if you have private insurance until your crisis escalates to a police activity try it some time i hope you don't have to i have had to for family members and friends so one of the best things that the v a does is comprehensive and very thorough analysis and treatment of people with these kind of social determinants of health particularly psychosocial aspects it is comprehensive both medically socially and i would argue geographically as well i come from the flyover own i grew up in the tri state area of nebraska as my new jersey roommate described it as you drove with me sticks of the sticks yes it is difficult to access healthcare due to the fast year graphic differences but one of the things v a does well and they did it well when i was a medical student in omaha in one thousand nine hundred seventy six is tell of health intel education and i think that's why one of the great prospects that it can be developed not ignored and allowed to wither on the vine it fulfills this important social need and it fulfills that promise to people who have served in now in this continuous war of nearly thirty years never before in our country's history have we had a situation like this yes they come back they're different than world war two veterans they're different than perhaps the vietnam veterans who saw enormous amounts of carnage but still the psychosocial aspects of what they come back and the burdens that they bear are incredible and need attention as well the v a is also very innovative innovative in their development of the first and probably still best comprehensive electronic medical records which really helps buying together a complex and diffuse healthcare system particularly in a teaching environment it's what it's the glue that helps hold us together and helps us do deliver really quality care where we have not just a record but an x ray at a fingertips reach i can look at a c t scan and scroll through it with one millimeter resolution while i lay on my back in the sunshine and in my backyard wireless the v a develop the best e m r they did it decades before anybody else and they did it for a fraction of cost because it was open source and it was not for profit and it wasn't a proprietary silo so the v a has done a lot of things in terms of innovation and if you want to look at the inflection of health care costs much of it is buried in the cost of proprietary competitive electronic medical records which i think is responsible for a huge part of the inflection curve of the cost we paid x amount of dollars for a comprehensive e m r it took us ten and ten years to implement it we thought we bought a lexus we could drive off the lot turned out it was creates a car parts used toyota car parts to quote a former director of our institution so i could go on at the innovation but i think the v a should be maintained it should be continued it should be funded are we can't even fund public education in our state let alone fund health care in this nation but we've got to decide as an electorate is health care a right or is it a privilege of the ever shrinking ability not just of those of us who have employee based health insurance but now it's to the point where you have to be wealthy i mean your your job insurance won't even cover psychiatric visits in the private sector and you won't even get a visit with a private psychiatrist for at least three weeks so i think the v maintained it should be improved there are systems of care that dedication should be held as a model as we evolve from our fractured for profit health insurance environment to a single payer environment like the having canada i don't think we should have a delivery system like the national health service in the united kingdom that's perhaps and believe it or not i can't believe i'm actually more moderate in that respect i think we could keep our system of providers like canada does but we need to have a single payer mechanism and we need universal access one of the advantages  when their demand expands they're the only one in the whole country who can contract their eligibility and the supply of patients i don't have that luxury at harborview tonight there are fifty six patients in a four hundred bed hospital at harborview who do not have a bed fifty six in patients and that's every night for fifteen years so i think keep the v a make it a model and we need a single payer mechanism for the financing and have to decide as a lecture it is a right or is it a privilege of the one percent thank you so i sense a troubling level of consensus among analysts this morning i heard a story on our local our local n p r station about the opening of  into these clinics about twenty five clinics around the country and this is the clinic is to support post nine eleven veterans and military families with mental health services regardless of veterans discharge status or ability to put the first clinic of its kind in the state so the need to create a clinic to serve post nine eleven nation and stephen cohen who actually is i wouldn't describe stephen cohen as a philanthropist he is actually one of the most notorious hedge fund managers in the country he was almost naturally indicted  and sent to jail for insider trading and i think the co inventor networks are a problem and a symptom one of the things cohen better networks do is and by the way the two hundred seventy million five million that he funded these clinics with for five years he could actually fund them for the rest of his life because he has something like fourteen billion dollars and it would represent very little but one of the and that is precisely the amount of money that was the inspector trading scandal but ok but what about the  and understaffed and also that because congress won't change this crazy rule about not letting veterans with other than honorable discharge is be cared for by the v a except for now there's an order that they get ninety days of mental health care which is not enough and they haven't and it added extra staff to do it i mean i i see this as as both is sort of a problem and it's a failure of the society you know significant adequately fund the v a i mean another problem with cohn's the con network is that all of his clinics are he said he was going to serve under served areas yet all of his clinics are being opened in places like seattle where they are ready v a clinics so there are a lot of people that are concerned that he's actually trying to set up a competitive health care system with the v a i mean i think some of the people  on this panel have pointed to the issue that you know part of the problem is that the v a is underfunded and understaffed we have forty three thousand vacancies in the v a and the secretary has said two hearings recently that he will not fill them so you are sort of i think setting up you know the v a for failure it's like the underfunding the public schools and you know making  the one thing that is pretty common is so many of the the guard folks come back from being from a deployment and put on their civilian clothes but they're still in the guard and they still want to go back they still have a military career and many of them are very reluctant to come into the v a and and  talk about p t s d or have mental health issues or have military sexual trauma because of a fear that that will end up getting into their record and affect their ability to be promoted or even stay in the military so there is you know it is a big issue it is particularly a big issue with women who suffer a military sexual trauma and i think it's something that the v a has been trying to address but it's  a challenging situation so yeah i would agree what was said and you know although i do find it odd that it's being placed you know right next to a military hospital  a large fear clinic you know the one thing that you said and i had read about this that that would be an advantage from my perspective is the opportunity to take their families you know one of the difficulties in the v a is that we can only take care of veterans and there's been talk over the years of expanding eligibility to family members and i think that would be an excellent improvement to the v a to expand that eligibility i would also say that you know in addition to sort of  directly starving the v a for resources one of the big shackles that's been applied is the inability to close under used facilities so these older facilities that don't have you know where resources could be transferred to those areas where there is high demand and increasing in rome and in the v a it's practically impossible and and for those who you know really want to know what happened in phoenix that's actually what happened that was the area of the country with the highest growth of new veteran iraq and your budgets based on your activity from three years ago so it's impossible really to respond promptly to those surges so you know i think in addition to you know sort of you know fully funding and not sending money out the door to have given v a leadership the opportunity which they haven't had for you know thirty years is like closing a military base only harder to sort of be able to adjust to the changing demographics and changing needs to go in and for the clinic that you mentioned one of the interesting pieces about it that you mentioned was the role of discharge in one's discharge status and the ways that that affects how much health care your you're eligible for and how much you are not and it plays into this idea that we earn our health care that that some are more deserving than others and i think there do need to be some things in life and in society that we do earn but i don't look at my children and think well which ones of you have earned your health care for this week and which ones of you hav i mean i think in day to day life it just doesn't work like that i don't think we actually think in terms of earning or privilege like rights or privileges we just think the communities around us need to be healthy for us to be healthy our families need to be healthy for us to be healthy the dishonorable discharge veteran needs to be healthy in order for me to be healthy so so i think it it it's it's maybe tapping into sort of this this piece that is kind of on answer or it's not answered fully or adequately enough around the role of discharge i have a colleague who was dishonorably discharged for drug use and then has struggled to have have a job so he has no health care and so he has absolutely no way to get help for his addiction problems and right like that begins to bypass whether you have the right to it or whether you've earned it or not that just has gate keeper mechanism that the v a is so good at there are more than eight categories there if your goal for vet you get it free for five years if your purple heart recipient right you were wounded in action you get it if decision discharged with a disability you can get it and there's various ratings on the percentage if you are southwest asia gulf war veteran you know afghanistan etc from ninety to ninety eight if you had discharge with the v a service disability if you're in vietnam from sixty two to seventy may seventy five you get it if you had head neck radiation treatment you can get it if you were at camp  during a certain period where their water was actually horribly poisoned which my brother a veteran of twenty six years tells me that the funding for the wall will take the money to ha contamination in our problems in flint michigan so that ability to fluctuate this incredibly labyrinthine eligibility requirements is of course very complex in terms of being able to take care of aging facilities i went to medical school and i went out to a rural clinic back in one nine hundred seventy s where back in those days that department of health education and welfare when they saw a need they went out and they set up trailers they set up trailers in the central valley of california they set up trailers in the yakima valley here and they expanded to meet fluctuating needs not with you know super expensive mini billion dollar facilities but with sometimes temporary because hopefully the need will fluctuate if we can never turn off this continuous war ok that you know there have been propositions in like there was a commission on care me and did you buy the the choice act where the commission came up with the idea of doing some pilot programs where you would use underutilized facilities to care for families of veterans i agree completely with kelly although i do think families of veterans do benefit from v a care in ways that we don't see but i think that they you could create pilot programs in underutilized facilities think you know there are a lot of assumptions here and you raised money on that that we are going to have a dwindling you know veteran population how do we know that i mean you know given our country's propensity to jump into conflict and also as i think anybody who's a physician on this panel and anybody who's a caregiver in the audience knows you can have a dwindling population that has higher needs you know i mean the veterans today have way more problems because of our amazing ability to tree yards on the battlefield i mean people who would have died in vietnam or world war two or korea lived today with horrendous chronic problems so you know i also think so i think that there can be experiments with sir you know with adding families and even you know we brought even non veteran patients why not i mean you know but  how etc etc i just want to raise one question because we've all talked about you know giving the right to care to all americans i think one of the fundamental on answered things that this country hasn't dealt with is actually calculating the real cost of war right in the real cost of war includes very well funded as opposed to underfunded v a and we have refused to do that is country  so i think you know the a in to kind of mention that what it actually has done historically quite well as innovate and i think the opportunities to innovate have been withheld from the organization for a couple of decades you know it's still i think there and could be unleashed you know one of my great disappointments is with the new e r h r's that v a is not allowed it's not being permitted to bring the innovation to it which needs to happen you know one great innovation i thought that jim will know about that was planned was actually not to build a hospital in denver the original plan actually was to lease  hospital space from the new and should medical center which was built down the street so the v a could have flexible hospital space could share laboratory and radiology facilities and then be able to flex up and down you know the v a pioneered building these super clinics there's once and then ohio where you know it's it's got all but inpatient beds and v a may not necessarily need to be in the  patient business in some communities there's also been a lot of talk about figuring out what the v a does well and what actually would be better provided in some other settings and give local  to me actually that's what the v a could do that's the leadership that the v a could provide just as it had before in sort of being able to experiment without the same financial risk as private health care systems and  june deception pass state park there's a museum to the civilian conservation corps it takes political will and leadership three hundred thousand young men in this country were put to work in the course a lot of confidence actually in the projections around the veteran population we just we don't fight wars the way we did in world war two in vietnam but i think that you know in the front of the v a building in washington d c is the mission statement for the department of veterans affairs handed down by abraham lincoln and it sounds a bit sexist today but you know it was abraham lincoln which is you know to care for he who bore the battle for his widow and his dot's the mission of the v a it's not about the brick and mortar that sits on the hill down the road it's about it's about that mission right it's about taking care of kelly and her brothers and sisters  and i think that v a going forward is going to have to partner with private sector to be able to do this i just you know steve said it the buildings are not in the right places anymore  was on a group in oregon going around and looking in doing town hall meetings around the state to talk about how things could be improved as people left the guard and i met this young man on out in pendleton oregon who had his leg blown off by an r p g and he wanted to know why he couldn't text message his doctor and get help and why he had to go to portland to get a new prosthesis and it wasn't so he could walk around it was so he could snowboard i think the expectations of a new generation of veterans are just very different and i don't think v a is going to be able to do it by trying to sustain the organization that it has today ok thanks for those