Roosevelt Room, August 4, 2009. Transcript provided by the White House
THE PRESIDENT: Well, listen, I appreciate all of you taking the time. We thought that this was a good time to check in before the break, partly because there are going to be a lot of the veterans conventions over the course of the next month, and we think we've got a great story to tell about where we're moving when it comes to how we treat our men and women who've served in the United States Armed Forces.
Obviously we have now between IraQ: and Afghanistan seen as experienced and as battle-hardened a group of veterans as we've seen in quite — in a generation, basically. They have performed with extraordinary valor. They're coming home to an economy that's weakened because of the financial crisis. We believed that it was very important for us to not just tinker around the edges but really make a forceful series of — take a forceful series of steps to make sure that the VA was equipped to provide the services that our veterans so richly deserve.
And as a consequence, my budget reflected the largest increase in VA funding in 30 years — $25 billion over five years that allows us to deal with post-traumatic stress disorder in a much more robust way; traumatic brain injury; allows us to open new VA clinics in rural communities so that people aren't having to travel 200 miles or a hundred miles to get services. It allows us to continue to improve our information technologies, the number of claims adjudicators so that we can start reducing the backlog of claims.
And when you combine these added resources with the extraordinary administrative improvements that General Shinseki — Secretary Shinseki has been promoting inside the VA, we think that we can create a much more customer-friendly operation.
We also have been placing a lot more emphasis on outreach because although there are hundreds of thousands of veterans who are using services, we know that there are hundreds of thousands more who may not know that benefits are available; and really working hard to make sure that every single veteran — not just of our active forces, but also the National Guard and reservists — are aware of the benefits that are available to them; and guiding them through that process we think is extraordinarily important.
We also are excited about the implementation of the Post-9/11 GI Bill. I highlighted that yesterday. My grandfather benefitted from the GI Bill, as did many members of the greatest generation. This is the next greatest generation, and they need to have that same support.
So when you look at the kind of educational benefits that our vets are going to be able to obtain through this legislation and the fact that these benefits are going to be transferable, what we expect is that once again a highly educated workforce growing out of a GI Bill is going to help to drive economic growth for many years to come, even as it provides a tangible reward for people who've made such extraordinary sacrifices on behalf of our country.
There are still issues that we are working on and addressing. As many of you — as all of you know, I emphasized the need for a seamless record-keeping relationship between the Pentagon and the VA, and we continue to work on that. The veterans organizations have been concerned about mandatory funding, and we've taken a step in the right direction I think with the advanced appropriations process that's now been embraced by both the House and the Senate.
So of all the things we've accomplished over the first seven months of my administration, one of the things I'm most proud of is that I really believe we have been true to our commitment to our veterans — the promises that I made during the campaign, we have followed through on — and it will provide tangible, concrete benefits to our veterans for years to come.
One of the best things I did for veterans was to appoint Eric Shinseki to the position of Secretary of the VA. So, Ric, if you want to just add to anything I said.
SECRETARY SHINSEKI: Just a couple points, and Mr. President, thanks for allowing me to participate today. And I would just underscore this 2010 budget that the President has provided us in terms of opportunity to address some long-standing issues.
One of the things that the President has focused me on is homeless vets — 131,000 sleeping on our streets tonight. And when we look at the problem — you know, homelessness is sort of the last indicator that things in a downward spiral aren't going right. It's about jobs; it's about education — a big piece of this was the GI Bill yesterday; it's about mental health and depression amongst veterans — they happen to lead in that category; substance abuse.
And so if you're addressing the 131,000 who sleep on the street, that's sort of a physical exercise at getting them off the street, but you're not doing much if you're not attacking the rest of the contributors that come in the top end of the funnel.
And this opportunity has provided to us, working with the HHS, with Labor, with Education, Small Business, and putting together our collective efforts to address the homeless problem. Addressing the homeless problem in this manner solves a lot of other issues that veterans wrestle with.
THE PRESIDENT: So why don't we just go around. I think we'll probably have time for each of you to ask a couple questions. So why don't you — we'll do one at a time and move back around.
Q: Thank you, Mr. President. The post-9/11 GI Bill, obviously a tremendous benefit for so many service members, but the enabling legislation left some National Guardsmen out of the picture — those who were activated after 9/11 under Title 32, which was cast by the previous administration as being part of the global war on terror. Do you believe the service of these men and women warrants this education benefit as well or not?
THE PRESIDENT: My general attitude is, is that if they've fought for this country, they should be eligible. Now, I confess that my budget folks may still be in conversations with members of Congress, the appropriations committees in sorting through anybody who's fallen through the cracks, and so I don't want to give you a definitive answer that we have solved this problem. But my general philosophy is, is that somebody who's served in uniform on behalf of our safety and security, that they should be eligible. And what I'll do is I'll make sure that somebody on my team, like Matt, follows up with you to give you a specific answer on the issue.
Q: Thank you. Do you have any feeling — perhaps Secretary Shinseki — of what the administration is doing to try to address that problem specifically?
SECRETARY SHINSEKI: Well, again, as the President said, we're — there are a number of these issues that we're still working through. We have an entire state that had some issues and that's being resolved, as well.
THE PRESIDENT: Yes, I don't know if you're familiar with — this is a good example of a similar type of issue. There was some question as to whether veterans who were attending private institutions in California were going to be eligible because of the unique nature of how California described its tuition versus its fees. We just got that resolved today. This will be part of a broader effort to work out the kinks in the system, and I would suggest that issues of eligibility are in a similar category. We want to be inclusive rather than exclusive; we want to encourage more people to use the program rather than less. And we'll give you sort of some details in terms of the conversation that's taken place once I find out from the staff.
Q: Thank you.
Q: Mr. President, you've talked about wanting to make sure there was seamless integration between people coming from active duty going into the VA system, making sure they don't fall through the cracks. We always see headlines about incidents where people have fallen through. What are the initiatives that are underway and what role has Secretary Gates also played in the conversations of making sure these two Cabinet departments do in fact serve these veterans, especially the wounded warriors?
THE PRESIDENT: Well, a couple of things that have happened — and I'll let Ric address a lot of the detailed negotiations between DOD and VA — but on the VA side, we've made sure that there is active outreach to members — or to those who are about to be discharged so that they understand very specifically what their benefits are. I think a lot of the reason people fall through the cracks is historically sometimes the VA has sat back and waited for people to come to them. And part of what Ric has been doing is to make sure that the VA is reaching out to them and letting them know what they can avail themselves of. That makes a big difference.
When you then combine that with an increase of claims adjusters by 4,000 since January of 2007, and you combine that with technological improvements that streamline the application process — you know, what we're trying to do is just break down the hurdles that exist between veterans and the VA.
Now, one of the things that I think we can do best to promote this seamless integration is getting a single electronic military service and medical record --
Q: Which you rolled out in April, wasn't it?
THE PRESIDENT: And we are I assume deep in the process of working through. The challenge — and Ric can amplify this — but one of the big challenges is, is essentially DOD and VA have different systems. This is a problem in the federal government generally when it comes to IT, is that you have everybody getting different contractors, setting up different systems, they're not interoperable. And so I think we are spending considerable time, effort, and money to figure out how to make them interoperable.
Do you want to give an update on that?
SECRETARY SHINSEKI: Donna, just a couple of things. First of all, the President's announcement in April sanctioned what Secretary Gates and I had initiated as discussions. There are a couple things here. You know, trying to do the seamless transition when a youngster takes off a uniform today and is inducted into the Veterans Department tomorrow — near impossible. And so what we've agreed to do is to create a system where a youngster takes the oath of office today, and while he or she is serving, we begin the process of creating an electronic record in DOD that is mirrored in VA.
So however long they serve, whether it's two years or 10 years, when they take the uniform off, a seamless transition has already occurred. They're a known quantity. We know where they've been. We know what injuries, what operations they've been on. To do that, we have to do what the President has asked us to do, and that's this virtual electronic — lifetime electronic record that's not just health care, but also administrative personnel.
And we have a pretty good health care electronic record in the VA today. DOD has one, as well. I lived under it for many years. I happen to be very proud of the one we have in VA. We have to get them to talk, or to come together, and that's what (inaudible) is about.
THE PRESIDENT: Tom.
Q: Thank you, Mr. President. I'd kind of like to combine two subjects into one question. And that is, first of all, you did make campaign promises about enrolling all veterans in VA health care. And, of course, what has been your first step in that is to add, I believe, 107,000 or something like that, of folks by raising it. So you're continuing a pattern that the Democratic Congress started last year.
But I'd like to address that in the context of other priorities. There's a lot of folks out there that could take advantage of — and I don't mean that in an inappropriate way — but take advantage of this if they want to use the VA health system for their drugs and so forth. Folks like — that haven't — I served years ago, was never injured, never expected to get into the system, but it could be that over time I'd be able to get my health benefits there.
And then you have a lot of recommendations that came out of the Veterans' Disability Benefits Commission two years ago. And one of them was that the VA disability system compensates an injured veteran for earnings loss, but it doesn't compensate for the quality of life that they may have lost. And the Commission recommended a 25 percent increase in disability benefits right away — a pretty expensive agenda item, I know.
But I'm wondering if in balancing the priorities, someone could look and say, well, on the one hand, you are keeping a campaign promise there; but on another hand, maybe there are other priorities that would affect people who are actually disabled in war and so forth, improve their benefits. Is that something that you discuss and have kicked around?
THE PRESIDENT: Well, that's something that I discuss not just relative to the VA, but relative to the entire government. We have finite resources, and governing is about choosing. I didn't make the commitment to reinstate eligibility for Priority 8 veterans lightly. I made that commitment based on stories that I have repeatedly heard where in some cases people making as little as $40,000 a year were deemed ineligible, depending on where they lived and then what the cost of living was. And they were suffering real hardship.
So what our proposal will allow is 500,000 additional veterans to be eligible for VA. Now --
Q: Your figure is right, by the way, mine was wrong. I was thinking of another program for 170,000.
THE PRESIDENT: And I think, if I'm not mistaken, about half of those will be in the 2010 budget. So it won't all be done in one fell swoop, but right away you've got a quarter-million veterans who are going to be eligible for additional benefits.
There's no doubt that disabled veterans have a special claim, I think, on all of us. And, you know, as Ric puts his budget together for 2010, we will certainly want to make sure that we are doing everything we need to do so that our disabled veterans can live full and active lives, and that their families are providing help if they're severely disabled, because that's a tremendous burden on those families, as well.
But I don't — this is one of those situations where I don't think you ever come up with the perfect solution. What we have to do is balance the need of somebody who isn't disabled, but has a very modest income and needs health care, and thought they were promised health care by the U.S. government when they signed up, with those who are more severely injured, making sure that they've got the special resources that they need. I don't think there's a perfect formula, but I think that we have obligations to both sets of veterans. And given the resources that we have, we want to try to meet as many of those obligations as we can.
Q: Thank you, Mr. President. You brought up PTSD in your opening remarks. And I'm sure you know of the VA report that said almost — I guess, more than a third of vets returning from IraQ: and Afghanistan are showing — going to VA for mental health issues. Nobody thinks that that number is going to go down with the continued deployments. You spoke about the money that you put in the system, but PTSD, mental health stress disorders — that hasn't been a forte of the VA in the past. There's the Vietnam era and issues with identifying and treating those sort of symptoms. So is throwing money at the problem going to be enough, or how are you going to approach the next wave of psychological disorders that are coming in?
THE PRESIDENT: Well, throwing money at the problem by itself is not enough, but money helps.
First of all, I do think that there's been a sea change in attitudes around post-traumatic stress disorder since the Vietnam era. And I think both DOD and the VA take the issue of PTSD very seriously.
One of the best things that we can do to reduce incidents of PTSD is to reduce the amount of time in theater without a break. And so the steps that we've taken to increase our forces, particularly army and Marines, the authorization that I've provided to Secretary Gates to advance the increase in forces for our army so that we can end stop-loss policy sooner than we otherwise would have been able to do — all those things are going to make a difference in reducing stress, because what you've seen is, is that the incidents of post-traumatic stress disorder increase with each deployment. So that's step number one.
Step number two is making sure that we are doing the screening that's necessary so that problems don't fester, and eliminating the stigma that may have historically existed when somebody is showing symptoms of PTSD, particularly if they're still in theater, or still on active duty. And I think that you've seen steps both within all the armed forces to talk about these issues, encourage people to avail themselves of services while they're in theater, but also when they get home. And that's then combined with the much more aggressive systematic screening that's now being done by the VA for those who are discharged.
And then the third part of it is to actually provide the mental health services once people have been identified as needing help. And money will pay for more counselors, more mental health specialists, more facilities. It will allow us to target specific aspects of PTSD, for example, women veterans. We are trying to make sure that there are — service is available for women veterans in every VA facility or as many VA facilities as we can. You know, issues of potential sexual abuse for women veterans is being addressed directly in a way that it hasn't been talked about in the past.
So I think that this kind of comprehensive approach will help, but it's something that is still going to require a lot of work. That's I think what Ric was referring to when he talked about looking at the homeless population. By the time somebody is homeless, I think it's safe to assume that we've missed a lot of warning signs of a lot of points of intervention, and that's what we're trying to — close the gap.
SECRETARY SHINSEKI: I think throwing money at this is probably a little — just a bit off point. We're hiring mental health care providers. We're up to 18,000 in the VA today. And part of that, we're — also have a national suicide hotline. When you call in, it is not a 911 operator; it's a mental health professional.
These folks have taken something like 150,000 phone calls and addressed the needs and, you know, focused people into getting help; 3,200 interventions online where suicides were in the process, but because you have a mental health professional recognizing some cues, with an electronic health record — you have a name, you know a location — you can begin to vector whether it's police or local authorities — to help; 3,200 interventions to date, one of them in Baghdad. A mother calls in, she's online with a son — we get through Bob Gate's DOD, unit commander is notified, walks in, the youngster's actions — you know, intervene.
We know a lot about PTSD, but we don't know enough. We know that PTSD has been there for all time. The 131,000 homeless veterans, many of them are Vietnam veterans, many of them started out with PTSD, and they went down that long road. What we don't know about PTSD, and this is why we have to put a lot of effort into research, why does Shinseki and Smith go through the same incident — Smith comes out the other side essentially unaffected — Shinseki, heavy impact. Well, there's something here that we don't understand. Is it personal makeup, resilience, how kids were raised, or whatever? But unlocking that door, for both DOD and VA, will be important, because it will help us understand how we can teach resilience. And to some degree, resilience does count here — so a lot of research work.
We're putting mental health into the primary care areas of each of our hospitals. And as the President indicated, 153 hospitals, all of them have been directed to have a women's program coordinator — and I think we're at 144 out of the 153 now. But by putting mental health into the primary care area of the hospital as opposed to mental health as a separate entity, we're trying to attack that stigma of "I'm going to mental health," as opposed to "I'm going to the hospital," where it's not so visible.
I think we have to remind ourselves we're dealing with 20-year-old youngsters. Some of this is just the invincibility of youth, having been that age at one time, where: I don't have a problem, you know, I can deal with this and I don't need help. We have got to work through that. I mean, that's part of the reason that at that age their insurance, their auto insurance is a heck of a lot more expensive because of that youthful aspect of their life. And so some of that is having to breakthrough just the invincibility of youth, convincing them that they have an issue; we can help.
We know if we get them into treatment they get better. We also know if we don't get them into treatment it doesn't get better, and most often it becomes debilitating.
Q: You --
THE PRESIDENT: This is your second question? (Laughter.)
Q: It can be my second question. It's building off of that. You're covering a lot of different topics in there. But when we sat down about this time last year in the campaign, you had said you wanted to see a change in attitude at the VA. So there have been quite a few reports up in Capitol Hill about frustration with how long electronic medical records are going to take with the GAO's female veterans report, with the PTSD report. So I'm — do you feel that you've seen that change in the change in the --
THE PRESIDENT: I think there's no doubt that we've had a change in attitude. Now, translating a change in attitude at the top with transforming a massive agency with — how many employees do you have there now?
SECRETARY SHINSEKI: Two-hundred and eighty-eighty thousand. THE PRESIDENT: Two-hundred and eighty-eighty thousand. I mean, this is a big operation. And so as much progress as we've made, I think that it's fair to say that this is a multi-year project. And we are going to be working vigilantly. We're going to keep on pushing. We're going to keep on prodding to make sure that both the VA and DOD understand these very human issues are dealt with in the most thoughtful and effective way as possible.
I'm confident that we're moving in the right direction. We're putting resources behind it. We're putting time and energy behind it. I'm focused on it personally. But it's going to take some time.
And I think we also have to acknowledge that, as I said before, there is a direct connection between the problems of the PTSD and the pace of military operations. As we are phasing down our operations in Iraq, we're going to see fewer PTSD cases coming out of Iraq; as we're seeing increased velocity of operations in Afghanistan, that's going to put more strain on the military personnel who are located there.
And this is why I take so seriously my role as Commander-In-Chief in deploying these young men and women, because no matter how good of a job DOD or VA is doing, war is a difficult, painful process. And we have to be mindful of that.
SECRETARY SHINSEKI: Let me add a point here, Mr. President. Leo, the 2010 budget begins in 56 days.
THE PRESIDENT: Sure. (Laughter.)
Q: Mr. President, health care reform is an important agenda item, perhaps the top. And I think all of us write not only for a veterans audience, but we act for active duty military and for retirees too. Secretary Gates, I know, Chairman Mullen — Admiral Mullen have expressed interest about TRICARE fees. They haven't been raised for retirees since 1995. Also, you have the VA health care system here. I wondered if you could put into perspective your goals for national health care reform and how it might affect, if at all, health care for active-duty members, for retirees and so forth, and for veterans. At some point do you see some kind of a universal health system that would affect all of them, or is it, in your mind, do you want to keep these systems apart?
THE PRESIDENT: Well, let me make a first point, and that is, eligibility for VA health care, TRICARE will not be affected by our efforts at broader health care reform. And I just had the American Legion Commander in here and wanted to make sure that that message gets out to our veterans because --
Q: I can't tell you how many e-mails I have from people that try to associate that.
THE PRESIDENT: Right, so I think it's very important to get the message out. If you're in the VA system, you're happy with your care, great, and we're not — we have no intention of changing your eligibility.
Obviously whatever health care system you're in, whether it's VA, TRICARE, private insurance, Medicare, we have a problem with health care generally in this country. We pay about $6,000 more per person than any other advanced nation, and our health outcomes are not much better and in some cases a little bit worse.
VA actually has probably made more progress than any other health care system out there over the last 25 years in improving quality, improving efficiency, creating a good bang for the health care dollar.
But there are still issues within the VA medical system when it comes to cost. TRICARE — bigger problems, and Bob Gates will talk to you about the degree to which his budget is being sucked up by health care inflation. And obviously the private sector as well as in Medicare and Medicaid, it's a huge problem.
So where I would say there's going to be a relationship is we are constantly looking at models of care that provide the highest quality at the lowest cost. And it turns out that there are systems like the Mayo Clinic or the Cleveland Clinic or Geisinger health systems, there are these pockets of excellence where not only are these rated as by far the best health care operations in the country, it turns out that they're in some cases a third cheaper than other health care systems.
So what we're trying to do is learn from what they're doing. It turns out that there are some common themes. They have a patient-centered model rather than a fee-centered model. So they're focused on not giving five tests to a patient, but rather giving the one test and having all the doctors present at the time that one test is administered to then coordinate care between primary care physicians and specialists. They all are interested in prevention and wellness. They all use electronic medical records very effectively to reduce errors.
So there are a set of proposals that we are introducing primarily on the Medicare side because that's where the government has the most leverage. We've got insurance reforms that we are initiating so that private insurers would have to abide by certain rules like not excluding people because of preexisting conditions.
All of these can end up having an effect in the sense that lessons learned in these systems can then be applied to what's the kind of care, the kind of services that are being providing to veterans and our active-duty military folks.
So in some cases, by the way, it goes the other way. Lessons that we've learned in the VA can actually be exported to other systems out there.
One specific issue, in addition to letting your readers know that if you're in the VA or TRICARE this will not force you to change systems — people should also know though that if they are eligible for VA benefits but, for example, live in an area where they might want to get a better deal because it's closer, for example, then veterans would be eligible potentially for this health care exchange where they could select from a different set of plans and still receive some help in paying for their premiums, depending on what their income levels were. So it'll actually give them more choice and more flexibility.
All right, I'm going to try to be very quick on these last two questions. I'm way over schedule.
Q: Secretary Shinseki, we talked out in Aspen. You had just come onboard at the disabled winter sports --
THE PRESIDENT: Why don't we do this? If your question is for Ric, why don't we hold it for you and --
Q: All right, well --
THE PRESIDENT: Oh, actually --
Q: Let me reframe it then.
THE PRESIDENT: Oh, okay, because I was going to let — I was going to take off. (Laughter.)
Q: All right, well, let me ask you. I'll tell you, he told me, as someone who came up through the military, veterans have been promised the sky and the moon, but he wants to be measured by what he delivers. And what I'm very curious about is what do you see as the big successes of what you've delivered so far, and what are your short-term — what should we be looking for next in terms of delivery?
THE PRESIDENT: Well, I think the budget is our biggest success because that will facilitate all the other changes that are going to need to be made. And the fact that we were able to get that budget passed through the House, through the Senate, that all the committees have been consulted — the appropriators know this is a priority of mine — I think that puts the VA on a much firmer footing, moving forward.
The key now is implementation, execution, and this is where the challenges of a 288,000-person agency becomes so important — is making sure that there is a culture within the VA that is consumer-friendly, that is oriented not towards keeping people out but bringing people in, giving them the services they need, doing it in a cost-efficient fashion. But I have great confidence, given Ric's track record, that he's going to be able to do that.
Q: Mr. President, the government has a long history of denial when it comes to force health issues — back to the 50's in the atomic testing and so forth; Agent Orange in the '70s; it goes on and on. And there's — now there's evidence a similar situation is playing out right now over the issue of respiratory illnesses and blood disorders with regard to the exposure to burn-pit smoke over in the theater. And I'm wondering if you're aware of the issue. And Mr. Secretary, how is the VA positioned to deal with that issue?
THE PRESIDENT: I am aware of it. And in all of these cases, my overriding mandate to my agencies is that you get the best science possible, and then you make decisions based on how we can protect our men and women in uniform; how can we treat those who have been harmed. I don't want us hiding the ball if there's a real problem there.
Now, I am absolutely convinced that our commanders in theater are doing everything they can to protect their men and women. And the key is to understand that our scientific knowledge and our medical knowledge may evolve, and if we find out that something is wrong, it might not have been anybody's fault, nobody may have known at the time, but nobody is served by denial or sweeping things under the rug.
Q: And the Pentagon is still officially hewing to the line that there are no long-term health risks associated with exposure to —
THE PRESIDENT: Well, I want to — I want this handled the same way that I'd want all issues handled, including Agent Orange and other issues, and that is that we have the best objective evidence available and that we make decisions from that standpoint, from that point, moving forward.
All right? Ric may want to follow up on some additional points on that. I do have to run.
Q: Thank you for your time.
THE PRESIDENT: I hope this was informative --
Q: Thanks for having us.
Q: Thank you very much.
Q: Thank you for having us. Happy Birthday, too.
THE PRESIDENT: Thank you. And tell all your readership I appreciate what they do for our country every day. Thank you.