information that they said they did. they subsequently had to recant their testimony and apologize to the committee for providing inaccurate information. my work on the homeland security subcommittee started, but i also co-chaired national commission on cybersecurity for the 45th presidency through the csi's commission, where we had cybersecurity experts both in and out of government from around the country sit on this commission and help us to develop a blue print of how best to provide cybersecurity for the country and produced a robust document that helps us to show where we really need to be to get this right. >> host: do you hear from your constituents on this issue? >> guest: some. in particular companies in the i.t. field and i.t. sector, in the cybersecurity sector that understand how important this issue really is. the other thing that we're also, i want to focus attention on, is

although this is also a national security threat, it poses a challenge and opportunity for us in creating jobs because we don't nearly have enough people in the field of cybersecurity that with the right skills to protect the nation in cyberspace. the director of the cia center for information technology basically said we only have about a thousand people that can offer that world class level in cyberspace when what we need is between 20,000 and 30,000 people. i've been looking for efforts involved in trying to get our young people engaged in this problem and get them interested in the field of cybersecurity. we launched a cyberchallenge at the high school level putting kids interested in cyber issues through a series of challenges and tests to test their cybersecurity skills and award them with prizes and it's the

idea of getting interested in a field that they just do, but to also get them thinking about this as a career field. we got to workheartedder in closing the -- work harder in closing the gap in i.t. and cyber. we have jobs available here, rhode island, and in the country, but it's a challenge to find people with the right skills to fill the jobs. i look at it as a jobs opportunity as well. >> host: democrat from rhode island, member of the armed services committee, serving as the top democrat in the emerging threats and capabilities subcommittee and also the co-founder of the house cybersecurity caucus, and he's been our guest on the communicates. thank you, congressman. >> guest: thank you.

>> the supreme court today held the first of three days of oral arguments on the 2010 health care law. the focus today was on the

anti-injux act that prohillary clintons a person subject to attacks from filing a lawsuit before that tax has been assessed or collected. if the court decides the penalty for failing to purchase health insurance is a tax, it would mean no one would be able to challenge the law until 2015. solicitor general and challengers to the law both agreed the anti-injux act should not stop the supreme court from reaching a decision based on the merits of the case. >> we'll hear argument this morning on case 398. mr. long? >> mr. chief justice, and may it please the court. the anti-injunction act imposes a pay-first, litigate later rule central to federal tax assessment and collection. the act applies to essentially

every tax penalty in the internal revenue code. there's no reason to think that congress made a special exception for the penalty imposed by section 5000a. on the on trair. -- on the contrary. there's three rules that the anti-injunction act applies here. first, the penalty shall be assessed and collected in the same manner as taxes. second, congress provided that penalties are included in taxes for assessment purposes. third, the section 5008 penalty bears the key of attacks. congress districted that the section 5008 penalty shall be assessed and collected in the same manner as taxes. that directive triggers the anti-injunction act which provides that no suit for the purpose of restraining

assessment or collection of any tax may be maintained in any court by any person. >> well that depends as a government points out on whether that directive is a directive to the secretary of the treasury as to how he goes about getting this penalty, or, rather, a directive to him and to the courts. all of the other directives there seem to me to be addressed to the secretary. why should this one be directed to the courts? would you say in the same manner? he goes about doing it in the same mapper, but the courts simply accept that manner of proceeding, but nonetheless, adjudicate the cases. >> well, i think they have a three-part answer to that, justice scalia. first the text does not say that the secretary shall assess and collect taxes in the same

manner. it just says that it shall be assessed in the same manner as a tax without addressing any party particularly. >> well, assessing and collecting in the same manner as a tax. >> well, the assessment -- the other two parts of the answer are as a practice call mannerment i don't think there's any dispute in this case that if the anti-injunction act does not apply, this penalty, this section penalty will as a practical manner be assessed and collected in a very different manner from other taxes and other tax penalties. there's three main differences. first, when the appty-injunction act applies, you have to pay the tax or penalty first and then litigate later to get it back with interest. second, you have to exhaust administrative remedies even after you pay the tax you can't immediately go to curat.

you have to go to the secretary and give the secretary six months to see if the matter can be resolved administratively, and third, even in the very carefully defined situations in which congress permitted challenges to attacks or a penalty before its paid, the secretary has to make the first move. the taxpayers never allowed to ruche into court before the tax -- before the secretary sends a notice of deficiency to start the process. now, if the anti-injunction act does not apply here, none of those rules apply. that's not just for this case, but that will be for every challenge to section 5008 punishment going forward. the taxpayer will be able to go to court at any time without exhausting administrative remedies. there's none of the limitations that apply in terms of you have to wait for the secretary to make -- >> why would administrative

exhaustive rule not be appliable? >> there's no prohibition on courts having the collection of the penalty, and you can simply -- >> the courts apply the exhaustion rule. i know you studied it, but i'm not following. why have the court if you didn't exhaust your remedies? >> well, you could do that, i think, as a matter of common law or judicially impose doctrine, but in the code itself which is -- the anti-injunction act is a essential statute and the code says, first says you have to pay the tax first and then litigate. that's the base line, and then in addition it says you must, and it's not common law, it's in the code, you must apply for a refund, wait six months, and i mean, none of the provisions are

extremely specific with specific -- >> they would apply even if the rule is not jurisdictional. the only difference would be that the court could enforce it or not enforce it in particular cases which brings me to the davis case, which i think is your biggest hurdle. it's a case similar to this in which the constitutionality of the social security act was there, and it's the application of the act, and, of course, if it's jurisdictional, you can't wave it. are you asking us to overrule the davis case. >> davis was decided during a period when this court interpreted the anti-injunction act as simply codifying the pre-statutory equitable principles that usually, but not always, prohibited a court from enjoying the assessment or collection of taxes, and so that understanding, which is what was the basis for the davis decision

was rejected by the court and a series of subsequent cases, bob jones, and so i would say the davis case was overruled by this court. >> why don't we follow the statutory language, and i know you argued the davis case has been over taken by later cases, but the language of the anti-injunction agent is no suit shall be maintained. it's remarkably similar to the language in and no civil action shall be instituted, and that formulation, no suit may be maintained, contrasts with the injunction act. it says a court shall now

enjoin. that tax injunction act is the same pattern as 2 # -- 2283 that says courts of united states may not have a proceeding in state court. both of those formulas, the tia and the no injunction against proceeding state law, directed to the court, the anti-injunction act, mike the statute -- like the statute at issue, says no suit shall be maintained, and it's been argued that that is suiter directed in contrast to court directed. >> right. well, i mean, this court has said several times that the tax up junction act was based on the anti-injunction act. you're quite right that the language is different, but we submit that the anti-injunction act itself by saying that no suit shall be maintained is

addressed to courts as well as litigants. i mean, after all, a case can want go from beginning to end without the active cooperation of the court. >> how is that different from no civil action for infringement shall be maintained and instituted. anything turn on that? >> well, it's -- i mean, it is -- perhaps a party could initiate an action without cooperation of the court, but to maintain that from beginning to end, again, requires the courts' compings, and even if -- even if the court were inclined to say as an official matter, if this statute came before us for the first time today given all your recent decisions on jurisdiction, that you might be inclined to say that is not a jurisdictional statute, a lot of water has gone over the dam here. the court has said multiple times that this is a jurisdictional statute, congress has not disturbed those

decisions. >> well, it was said many times, but is there any case in which the result would have been different if the anti-injunction agent were not viewed as jurisdictional, but instead viewed as a mandatory claims processing rule? >> there's a number of cases that the court dismissed saying it's jurisdictional. as i read the cases, i don't think any of of them would come out differently because i don't think we had a case where the argument was, well, the government waived this, so, you know, even if it's not jurisdictional -- >> well, the clearest way of distinguishing between the jurisdictional provision and monday tear claims processing rule is whether it can be waived, and whether the court feels that it has an obligation to raise the issue. now, if there's a lot of cases that call it jurisdictional, but none would have come out differently, if the

antiinjunction act was a claims processing rule, there's the one side. the other side is where the court accepted the waiver oi the solicitor general, the sunshine case where there was a waiver, and there's the williams-packing case which is somewhat hard to understand as viewing the anti-injunction act as a jurisdictional provision. the court said there could be a suit if there's no way the government could win and the plaintiff would suffer harm. now, doesn't that sound like an equitable acception to the anti-injunction act? >> no. i think the best interpretation of the court's cases is that it was interpreting a jurisdictional statute, and, indeed, in williams-packing the court said it was a just dictional statute, but, again, even if you had doubts about simply the cases, there's more than that because congress has -- is not only not disturbed this court's decision stating

that statute is jurisdictional, but they've passed numerous amendments to the anti-injunction agent. >> you can't separate the two points, the idea that congress is acquiesced in what we said only helps you if what we said is consistent. you pointed out in your brief that we've gone back and forth whether it's jurisdictional or not. even if the court act applies acquiesced it, i don't know -- >> what you said is consistent for 50 years. the period of inconsistency was after the first 50 years since the statute was enacted in 1867, and there was a period, as i said, when the court was allowing extraordinary circumstances exceptions and equitable exceptions, but then quickly, it cut back on that, and since williams, you've been utterly consistent. >> even since williams r there was scarce, csh south carolina,

and that can be an exception to the rule which would be inconsistent with thinking that the rule is jurisdictional. >> well, again, i mean, i think the best understanding of south carolina is not that it's an equitable interpretation, but a statute that would interpret in in light of its purpose and deciding in that special case that it's a very narrow exception. >> mr. long, in bowles, the court looked to the long history of appellate issues of being jurisdictional in a traditional sense, but as a pure jurisdiction rule, and from all the questions here, i counted four cases in a court's history where that court had the general

and reached the tax issue. i have at least three cases, one of them just mentioned by justice kagan where exceptions to the rule were read in. given that history, regardless how we define just diction statutes in recent times, don't -- suspect the fairer statement that congress has accepted that in the extraordinary case we will hear the case? >> no, justice, because in monitoring of the amendments which have come in the 70 #s and the 1990s and 2000s, the congress actually framed the limited exceptions to the anti-injunction act in jurisdictional term, and it's written many of the expressed exceptions by saying notwithstanding section 7421. >> doesn't that just prove that it knows the court will impose a

claims processing rule with many circumstances and in those in which they specifically don't want to court to, it has to be clearer? >> but congress says nowithstanding 7421 the court shall have jurisdiction to restrain the assessment and collection of taxes. >> but you go back to the question that justice alito asked, assuming we find this is not jurisdictional, what's the parade horribles that you see occurring if we call this a mandatory claim processing rule? what kinds of cases do you imagine that courts will reach? >> right. well, first of all, i think you'd be saying for the rebound statute as well as for the anti-injunction act, with similar wording, so if the an hi tf injunction act is not jurisdictional, i think that's

going to apply to the refund statute, the statute that says you have to first ask for a refund and file, you know, within certain times, and so it would be both of those statutes, and, you know, we are dealing with taxes here, people -- >> that was not the question. my question was if we deem this a mandatory claim processing rule -- >> right. >> what cases do you imagine courts will reach on what grounds? assuming the government does its job and comes in and raises the aia as an immediate defense -- >> well -- >> where can a court then reach the question despite -- >> that would certainly be the first class of cases that occur to me where if the government does not raise it in a timely way, it could be waved. i would think plaintiffs would see if there's some clever way to get a suit going that wouldn't immediately be apparent -- >> assumes the lack of competency of the government which i don't, but what other

types of cases? >> i don't think you're going to come up with any, but i think your response is you could say that about any gurs -- jurisdictional rule. if it's not jurisdictional, you'll have an intelligent federal court deciding whether you're going to make an exception, and there will be no parade of horribles because all federal courts are intelligent. [laughter] it seems to me to be a question you can't answer. it's a question which asks why should there be any jurisdictional rules? you think there should be. >> and justice scalia, honestly, i can't predict what would happen, but i would say that not all people who litigate about federal taxes are necessarily rational, and i think there would be -- >> losing the second half of the argument and spent all the time so far in jurisdiction, and i accept pretty much, probably

leaning in your favor on jurisdiction, but where i see the problem is in the second part because the second part says restraining the tax here, congress has nowhere used the word "tax," but what it says is "penalty," and moreover this is not in the internal revenue code, but for purposes of collection, and so why is this a tax? i know you point to certain sentences that talk about taxes within the code, and this is not a -- this is not attached to a tax, but a health care requirement. why does it fall within that word? >> well, i mean, the first point is our initial submission is you don't have to determine this is a tax in order to find the anti-injunction applies because court said it shall be assessed

and collected in the same manner as a tax even if it's a tax penalty and not a tax. >> that doesn't mean the aia applies. i mean, and then they provide exceptions, but it doesn't mean the aia applies. it says in the same manner as. it is then attached to chapter 68, well, is references that as being the manner of, well, then if being applied or if it's being collected in the same manner as a tax, it doesn't automatically make it a tax, particularly since the reason for the aia are to prevent interference with revenue sources, and here an advanced attack on this does not interfere with the collection of revenues. i mean, you read the argument,

as have i, but i want to know what you say in response to those arguments. >> specifically on the argument that it is actually a tax, even setting aside the point that it should be assessed and collected in the same mapper as a tax -- manner as a tax, the anti-injunction act uses the term "tax," but doesn't define it somewhere to my surprise, tax is not defined anywhere in the tax code, and by the time they passed it, tax had a very broad definition, broad enough to include this exaction which is codified in the internal revenue code as part of the taxpayers annual income tax return, the amount of liability, and whether you owe the liability is based, in part, on your income, assessed and collected by the irs. >> it leaves some doubt, mr. long, for the reasons that justice breyer said, and i thought that we had a principle

that ousters jurisdiction are narrowly construed, you know, unless it's clear courts are not deprived of jurisdiction. i find it hard to think that this is clear. whatever else it is, it's easy to think it's not clear. >> well, i mean, the anti-up junction act applies to not only every tax in the code, but as far as i can tell to every tax ment in -- punishment in the code. >> mr. long, you said before, and i think you were quite right, that the tax injunction act is on the anti-injunction act, and under the tax injunction act, what can't be joined is an assessment for the purpose of raising revenues. the tax injunction act does not apply to penalties that are

designed to induce compliance with the law rather than to raise revenue, and this is not a revenue raising measure because if it's successful, nobody will pay the penalty, and there will be no revenue to raise. >> well, in bob jones, the court said that they had gotten out of the business of trying to determine whether an exaction is primarily where the new raising or primarily regulatory, and this one certainly is expected to raise substantial amounts of revenues, at least $4 l 34 -- $4 million a year. >> it's off the statute that nominated the exaction as a tax. here we have one where the congress is not the nominating, but it has a tax that's nominating it as a penalty. >> that's absolutely right, and that's obviously why if it were

called a tax, there would be no question that the anti-injunction would be wise. >> absolutely. even the section of code you referred 20 previously, the one following 7421, the aia, it does very clearly make a difference in 7422, make a difference between tax and penalty. very explicit. >> yes, it does. that's correct. there's in other places -- >> the best tax collection i found in your favor is many the brief with a whole list. i had my law clerk look them up, and it seems they all fall into the categories of either one, these are punishments that were penalties assessed for not paying taxes, or, two, they involve matters that were called by the court, taxes, or, three, in some instances they were deemed by the code to be taxes. now, what we have here is something that's in a different

statute that doesn't use the word "tax" once, other than a collection device, and, in fact, in addition, the underlying iai reason, which is to say to the solicitor general, we don't care what you think. we, in congress, don't want you in court where the revenue of a state, tax injunction act, or the revenue of a federal government is at stake, and therefore, you can't waive it. now, i got that. here it's not at stake. here's all the differences i just mentioned, and so i asked that because i want to hear your response. >> well, i mean, there are penalties in the internal revenue code that you really couldn't say are related in any close way to some other tax provision. there's a penalty zeused in the briefs for selling diesel fuel that doesn't comply with epa

regulations. there's all kinds of penalties in the code, and i think -- >> mr. long, aren't there places in this act, fees and penalties, that were specifically put under the anti-injunction act? there's one on health care plans. there's one on pharmaceutical manufacturers where congress specifically said the anti-injunction act is triggered for those. it does not say that here. wouldn't that suggest that congress meant for a different result to obtain? >> well, i mean, congress didn't use the language, the anti- injunction act. >> no, but in section 9008 and section -9d -- 9010, it referred to the code of where the anti-injunction code is. >> picks up proceed childrens and provision -- proceed chiewrs and provisions, and there's fees, but congress

did not provide in the sections themselveses that it should be paid with part of a tax return. they were free standing fees, and by using that subtitle f-language, they plugged in a whole set of rules how to collect and administer fee, and it went not just to assessment and collection in the irs recognized this, but to examination, privacy, a whole series of additional things, and it's a mace take -- mistake saying we want this to apply. they are doing more than that, and, yes, i grant you, look at section 50 00a where they say, well, they could have been clearer about saying the anti-injunction act applied, and that's true, but, again, they were trying to accomplish a lot. ..

and again, it's become the center of a series of provisions that carefully control the circumstances in which litigation about federal taxes

can take place. >> there's another argument that has been made that i would like you to address, and that is all this talk about tax penalties because this is not challenging the the penalty, this is challenging the provision and the argument is made that if indeed must law is constitutional, then these and competence will not resist the penalty. so what they are seeking is a determination that is stated separately from the penalty that must fly as unconstitutional, and if that's so that's the end of the case. if it's not so, they are not resisting the penalty.

>> i think that argument doesn't work for two reasons. first if you look of the plaintiff's complaint the challenge the minimum coverage requirement and the penalty, page 122 of the appendix they challenged the requirement that the individuals obtain health care coverage and pay a penalty. >> if that is the problem they can take that out. stomach yes or another complaint would be filed but still that is a serious problem but even if they come from a different complaint, i don't think in this case you can separate the minimum coverage requirement from the penalty because the penalty is the sole means of enforcing the minimum coverage requirement, so first i think these plaintiffs would not be satisfied if the court or to render a judgment saying the

requirement is invalidated in the penalty or remains standing. anybody that doesn't have insurance has to pay the penalty and they have to pay a penalty equal to the cost of insurance and they wouldn't even have insurance. >> they say they want to obey law and your argument puts them in the position of having to disobey the law and order to obtain their review of the claim. what is your answer to that? >> i can't find that in the declaration. i don't see a statement they will never incur a penalty under any circumstances. but even if that were so, what this court has said in united americans is that act bars any suit not just to enjoy the collection of your own taxes but the collection of anyone's taxes, so even if it were true that these plaintiffs were not interested in the penalty and would never pay the penalty, if

they were to succeed in this case striking down the minimum coverage requirement, the inevitable result would be that the penalty what the call as well because the government couldn't collect the penalty for failing to follow the unconstitutional requirement and would be barred because it would be the suit that would prevent the collection. >> let me take this back to justice kennedy's question for the purpose of language and to get you interpret the statute to mean the following for the purpose of means having the effect of the, is that correct? >> the court moves a similar kind of argument made by the plaintiff in that case inevitable but this is what the suit is about. there are two sides of the same mcerlane that is the primary purpose of the suit, and its --

you can to by clever pleading get away from that. that's the nature. >> aren't you trying to rewrite the statute in a way? it has to sections. one is you have to have insurance and the affair is the sanction. it has two different sets the exception, correspondence to the different sections. you are trying to suggest the statute says it's your choice. either by insurance or pay the fee but that's not the way the statute reads, and the congress must be supposed, you know, made the decision that shouldn't be the way the statute reads and it should instead be a rate of the free command in the penalty attached to that command. >> i wouldn't argue this statute is a perfect model of clarity but i do feel the most reasonable way to lead the entire statute is that it does

impose a single obligation to pay a penalty if you are and applicable individual and you are not subject to extension and the reason i say that is if you look at the exemptions from the penalty the first one is you are exempt from the penalty because you can't afford to purchase insurance and it doesn't seem reasonable to interpret the statute as congress having said this person is exempt from paying the penalty because they can't afford to buy insurance however there is the obligation to buy insurance that just doesn't seem reasonable so why do think of awaits -- i certainly wouldn't argue it's clear, but that's the best way to understand the statute as a whole. but that's not the central to the question that we are discussing now whether the fact applies.

>> can you tell me why you think the solicitor general's reading who creates a problem? >> going back if the result were to say simply this is not -- i'm sorry, the solicitor general's readings. >> it's a jurisdictional bar but there is an exemption for those items converse has designated as penalties that are not taxes. >> would create the fewest problems as understanding at triet my main objection to the solicitor general reading is i don't think it makes a lot of sense. basically the solicitor general says every penny in the code, every other penny in the care act -- >> that's carrying it too far because if it's if it is designated as a textbook conquers the mix subject and that is most of the tax code

with come and he says for those portions of the affordable care act did designate so it's only -- and i have another statute and going to ask if there's another one it's only for those statutes and which congress has designated as something as a penalty not indicated its attack they don't fall within. >> my take is if you adopt the solicitor general's approach, there are probably three penalties for alcohol and tobacco offenses, 51, 14 c, 5684i think would be difficult to distinguish from this one for the penalty to disclose the political contributions of there's no further questions. >> thank you, mr. long.

>> general? >> mr. chief justice may i please the court this case presents issues tickets in consideration of those issues. >> that is so even though the act is a jurisdictional limit that serves with this court described as an exceedingly strong interest in protecting the stability of the federal government. and even though the minimum provision of the affordable care act is an exercise of conagra's taxing power as well as its commerce power, congress has authority under the power to enact the measure not labeled as the tax and it did so when it put the section into the internal revenue code but for the purposes of the antiinjunction act, the precise language the congress used is determinative and there is no

language in the antiand junction ek minow language in section 5000 of the affordable care act or the internal revenue code generally that provides a textural structure -- >> you are arguing that the penalty is not the tax. tomorrow you were going to be back and are giving the penalty is tax. have they ever held something that is the tax for purposes of the taxing power under the constitution isn't a tax under the antiinjunction act? >> no, just as alito but in the tax cases that something can be a constitutional exercise of the taxing power whether or not it is called a tax and we will conduct tomorrow was different from the nature of the inquiry that we will conduct today. tomorrow the question is whether congress has the authority to enact it and doesn't have a

despondent affect on that analysis today we are construing five space pre-tax where the precise choice of words does have an effect. speaking of the child labor cases because the court said that the tax which tax alone was a tax subject to the aiea and then it said it was beyond the detection in the case, correct? >> yes, i do think, justice, that with respect to one of the arguments that my friend has made in the briefings it is a second victim problem because i think the hour argument on the constitutionality of the taxing power is essentially that the affordable care act provision is the same thing as the provision the was held unconstitutional, but on the same day the court issued the antiinjunction that

barred the challenge to that provision even though the court concluded that it was invalid under the talks power, so the -- and i think the reason for that has been quite clear now after packing and bob jones that to find the antiinjunction act doesn't apply to something that otherwise would be attacked and trigger you have to conclude there is no substantial argument that can be made as the tax we don't have that here so i don't think you can get around the act if the court were to read as it should be read on that theory. >> the basic question about your argument, if you are right about the second part, that is for the purposes of the statute, the antiinjunction statute, this penalty does not constitute at

times. then does the court meet to decide whether the act in other cases where it does involve the attacks is jurisdictional? >> no, i apologize if i am creating confusion about that, justice ginsburg. we think by far the better route is to understand the statute as we have proposed that it be construed from the perspective of the united states and i would like to take a minute on this the idea that the antiinjunction act would be construed as not being the jurisdiction is very troubling and we don't think that it's correct, and i would if i could fall upon a question, justice ginsburg that you asked in terms of the language of antiinjunction act of 74 which can be found page 16 of the appendix to the briefing. i ask the court to compare that to the language of the next

provision in the code which is on the next page of the appendix which is the refund statute which we talked about a little bit so far this morning 74, 20 to a. of the statute the court held was jurisdictional, and the court held that the statute of limitations that applies to the refund statute cases is jurisdictional. the languages 7422a is virtually identical to the language. >> that's correct also in the context you have the sovereign immunity problem in which we presume that hasn't been played. >> originally they were the same provision they were only separated out later. so i do think that is the strongest indication, justice ginsburg, that 74218 -- >> i asked you if you are right

that this penalty is not covered by section 7421 come if you are right about that, why should we deal with the jurisdictional question at all because this statute the way we read it doesn't involve the tax to the antiinjunction act? >> that is our position and the reason we don't -- for fy. >> we need not decide. >> there would be no reason to decide. [laughter] >> justice kennedy i think we want to know the answer to a lot of things in this case, but i do think that the prudent course here is to construe the statute in the manner that we redid. but there was a discussion earlier about why does the government where to have the

attorneys etc command to be in your argument by saying would be troubling. i would like to comment on that to toe the party what is in its best interest would seem to me there might be some instances the government would want to litigate the validity of the tax and would want to read that you say that's not true that it's very troubling. estimate one is the problem identified the defense not jurisdictional and the courts have the authority to craft equitable inspections and it may seem from where we stand now that that authority is or could be very tightly cat and, but if the court were to conclude that isn't jurisdictional that those in power the courts to find other circumstances in which they might find it equitable to allow cases to go forward in the absence despite the existence and second, certainly not going

to stand up here and disparage the attorneys of the united states in the slightest. the reality is it this isn't jurisdictional the mets open to the argument that subject to the forfeiture failing to raise it in an answer and that is a troubling prospect. >> how likely is it? the government is going to be defending piece suits how likely is it the government will overlook the antiinjunction act? it seems to me this is the government saying it's at the government option. >> that is not our assessment of the interest of the united states, justice ginsburg, and we do think that the right way to go in this case is to read the statute as not applying to the minimum coverage. >> it was the calculation of the interest of the united states

that the predecessor made in the davis case. they're the solicitor general exercised the sanction to waive antiinjunction act and that couldn't be done if it were jurisdictional. >> that's true mr. chief justice. several points about that, we do agree with the analysis that davis occurred during the time and much the standard notte case the court had interpreted the antiinjunction active doing no more than codify in the traditional equitable principles that allow the court's discretion to conclude in certain circumstances a case can go forward. the packing repudiated that analysis, and bob jones against simon repudiated that analysis and said no, we are no longer abiding by that. it's true the case hasn't formally been overruled, but we do think that it's fundamentally

inconsistent with the court's understanding. >> shareholders sued the corporation and the remedy corporations shouldn't pay the money for the tax authority but that isn't actually an injunction against the tax authority. they are not restraining the collection. they say to the taxpayer don't pay. >> in fairness the united states intervened in the case and was a party, and so not so far as i like i guess. let's do it again because that goes too far. that is restraining the tax and payment of the tax. estimate you don't want to let that go. >> because it's a jurisdictional as the court understands it

isn't weevil and therefore we don't think that that part of the decision is wally. >> justice ginsberg suggested the language was very similar as it is here but even further similarities on the point about the provision in question wasn't in title xxviii and its pointed up the provision had numerous exceptions to it fifth. it's been created by the court over the years and reads though christian was essentially what about timing of came to court after you file your registration come to court after how you pay your taxes it seems and multiple respects with this case why is

that wrong? >> i don't think so, justice kagan. i guess i'm repeating myself and i apologize. the analog is the next provision in the united states code 7422a that the court has held this jurisdictional and raised in exactly the same way as 7421 in fact as i said they were the same provision back in the early days that is the closest analogue. it is actually 7422 that's the statute that says do something first. but this statute is a flat out command that -- >> i get the point but if you comment on the similarities to this case how do you think it is different at all? >> if the best answer to that is that there are no magic words in that history and the context matters as the court said in henderson and the history context here is 7422 and 7421

function together. >> sufficiently strong explains jurisdictional nature of that interest applies here and you come to court as a fundamentally different set of interests at stake so we do think that makes a big difference. >> are we still biting jurisdiction from the processing has you register before you can sue there are a lot of things to do so you have to pay filing fees before you can file the complaint. >> we do think it is very much in that nature of indifference. from this case one way i think it is helpful to get at this is to look at the history. we started a string of court repeal cases in the footnote in

the opening brief and over time it's been consistent the court of appeals has treated the act as a jurisdictional provisions. again the court agrees with the construction there is no need to reach this issue but they have one of the cases the district court in that case had dismissed the complaint under the federal 12 -- the court of appeals sent it back to the structures under 12 be one which is the subject matter of jurisdiction provision, so i do think that to the extent this is jurisdictional but it doesn't need to be before the court because the statutory argument. >> on the statutory construction, is there any other exact under the internal revenue code? that wouldn't qualify as a tax or antiinjunction act purposes or 5,000 a?

>> it's not quite out there all by itself. there are other provisions that all outside of chapter 68 and therefore wouldn't be governed by the instruction which answers the questions for most penalties. the ones that we've identified and i may be overlapping a little bit here one is 26, 857 which us certain penalties in connection with the administration of real estate investment trust the the there are provisions that he identified in his brief section 603 of the code which imposes certain penalties for the requirements with foreign corporations. we have a footnote 26 identified

three provisions mr. long also identified about tobacco. >> could we address the question of whether there are any the collapses to buy -- do not buy health insurance is the only consequence the payment of the penalty? the private respondents argue there are other political consequences such as for people on probation who are disobeying law if they don't buy health insurance they would be disobey the law and could be subject to a rebuild. >> it isn't a correct reading, justice sotomayor. the only consequence that ensues is the tax penalty. and we have made a

representation and a was a carefully made a representation that it is the interpretation of the agencies charged with interpreting the statute, the treasury department and the department of health and human services the there is no other consequence apart from the penalty. i do think if i could talk for a couple of minutes about the argument that was discussed as to whether this could be conceived of as a just challenging the requirement which is entirely standalone based on the instance is drawn from the exemptions really don't think that is right and if i could spend a minute i feel it's important. the exemptions in section 5000 it is true there are the categories of exemptions to the penalty and exemptions to the subsection requirement, but i think not only as a practical matter but even as a legal

matter they both function as exceptions to the requirement. first as a practical matter, one of those exemptions is a hardship exemption and if you'll bear with me for one minute page 11a of the briefed it provides that person can go to the secretary and obtain a hardship exemption which would as a former matter compliance with the penalty someone who has gone to an official in the united states and obtained the exemption would nonetheless be in the position of being in the law breaker. another way in which you can get to the same conclusion slightly differently is by considering the provision on page ten which is five those and a members of indian tribes. other member tribes are xm only

from the penalty on the structure of the statute but the reason for this because the murders of indian tribes of to their health care through the indian health service which is a system that doesn't involve insurance at all in a different system they were taken out of the statute because they get it to a different system and it doesn't make any sense to think the person getting their health care through the indian health service are violating the law because only from the penalty but still under the legal obligation having insurance when the point of this -- >> is you're point that this was an artful drafting by congress to the extent there's an exemption under the penalty from the legal obligation? >> i guess what i would say, your honor, is the way in which the statute is drafted doesn't permit the inference that my friends are trying to draw from it isn't an additional text will indication of that page 13th 14

u.s. c.a. section 18 to zero this is a provision that provides a certification certain individuals can get and it contains a quote and it says an individual with a certification is exempt from the requirement under section 5008 by reason one of such code is entitled to a certificate that allows for the enrollment of the particular program for this category of people that you can see is an exemption from under 5,000 which is the exemption from the penalty and not the underlining requirement is as the congress

says an exemption from the requirement of -- >> it is directly applicable individual should ensure that the individual has the minimum essentials coverage and you are saying that it doesn't really mean that. if you're not subject to the penalty you're not under an obligation to maintain the coverage. >> that is what congress is saying in the provision i just pointed to and by virtue of the fact the way the exemptions work i just think that's reading this in context that is the stronger reading of the statute. >> it makes it easy for the government to drop you in the future. you've been under the law also object to this from the penalty seóul you have to do is take away the penalty. >> i don't think so mr. chief justice, we think this is the fair reading of the statute

could you cannot infer somebody extend from the penalty even though there is an obligation to have insurance that isn't a fair reading of the statute. islamic the nature of their representation, the only consequence is the penalty. suppose a person doesn't purchase insurance a person that is obligated to do so under the statute pays the penalty instead and that person finds herself in a position she is asked have you ever violated any federal law, with a person have violated the federal law? >> our position is that person should give the answer. >> and that's because -- >> if they don't pay the tax they violate the law. >> as long as they pay the penalty -- >> then they are in compliance with a lot.

laughter kucinich if they pay the tax penalty. >> supposed a person who has been receiving medical care in emergency room has no health insurance but over the years goes to the emergency room for medical care, goes to the emergency room and the hospital says you are eligible for medicaid, enrolling in medicaid and the persons as i don't want that, i want to continue to just get care from the emergency room. will the hospital be able to point to the mandate and say you are obligated to enroll? >> i don't think so for the same reason i just gave. i think the answer in that situation is that person, assuming what that person does not medicaid will not be in the situation they are facing the

tax penalty. >> so the hospital will will continue to give them care and be enrolled in medicare. so you have a moral obligation to do it the congress would say you have to enroll. skype it's fair to say the congress wants people in that position to sign up for medicaid. that's right and the statute is structured to accomplish that objective but the reality is the only consequence of noncompliance is the penalty. >> but i thought people who were eligible for medicaid were subject to the penalty. i could just be wrong. >> the penalties keep in coming and its key to a number of things. one is are you making all the money that you are not obligated to file the tax return and if you are in that situation you're

not subject to the penalty and it's also if the cost of insurance would be more than 8% of your income you are not subject to the penalty, so there isn't a precise mapping between somebody's income level at the present moment that will depend on where things are. but for people below the poverty line it's almost inconceivable that they will ever be subject to the penalty and they would after the medicaid reform be eligible for medicaid. >> it's you're point that what we want to do is get money for these people that will help pay but they don't they are going to pay this penalty and that will help the fact we put the latter brings it from the taxing power but as far as the act is concerned about the injunction the call that a penalty and not tax for a reason they want it to

fall out of that it cetera. is that the heart of what you are saying? >> it didn't give any other construction in the affordable character the revenue code that should be treated as a tax. >> i thought you just agreed with justice brought year one of the purpose is to raise revenue. >> it's been predicted that it will raise revenue but even though that's the case that would be true of any penalty that would raise revenue but even though that is the case there needs to be in the statute this panel she believed the penalty should be treated for the purposes that is what is lacking. there may be a lot of people that set the penalty and disagree with what they should be assessed at velte at all if the calculation and the amount of the penalties.

under your interpretation of the lack of them can now go to court and of them are barred by the injunction act to respect those are different things. for the reasons justice kennedy said justin matej questions all of the other doctrines in the remedies and related doctrines would still be there and the united states would rely on those circumstances, and so why don't think the answer is -- >> the former commissioners of the irs followed a brief that your interpretation will lead to the flooded litigation. they are wrong on that? >> we've taken this position after careful consideration and we assess the interest in the united states and we think that we are in the right place. >> tell me something. why isn't this subject to the same bar that you listed in your brief. the tax court at least so far considers constitutional challenges to statutes, so why

isn't this case subject to a dismissal failure to exhaust? >> would go to the original amount and that is a different situation from this case. if the court has no further questions. >> thank you congenital. estimate what we do not whether the act is a jurisdictional. justice ginsburg for the reasons his adjusted we think the text of the antiinjunction that from the text of the statute that was unanimously held to be non-jurisdictional three of the statute said no sood shall be instituted. the statute says none shall be maintained.

>> week renounce the statutes at the institute on less it is registered. >> unless the copyright is registered and this goes to the character of the lawsuit register the copyright. >> why is that the following? >> he mandamus it with copyright infringement tough hoke. >> it's a precondition p analysis to the kennel desperate condition as pay your taxes if >> that's not true that sood has nothing to do with hearing the action. it has to do with the form of relief the concourses boring. it's not permitting. it's not a tax case you can come and afterwards it's not permitting the court to exercise what otherwise would be one of its problems.

estimate it has to be the same challenge, just as suddenly -- justice sotomayor. or it doesn't apply. you are right that once you pay your taxes and final for a refund action, the act of filing the texas converts the suit from one perspective relief into one in money damages and in that sense you can think of the statute as a remedial limitation on the court. but whether you think of it as an exhaustion requirement or the remedial limitation, neither of those is jurisdictional in you said the remedial limitation doesn't go -- >> it seems strange to think of a law that says no court can entertain a certain action and give a certain remedy as merely a claim processing rule. the court is being ousted from

what would otherwise be its power to hear something. estimates being the lead is the right way of looking at it. the jurisdictional apparatus and the district court is present, perspectives relief under 1331, money damages action number 1346. if the injunction act were a jurisdiction ousting one might have expected it to be title xxviii and to qualify the statutes and to use the jurisdictional. spec how do you deal with this case where we talked about the language of the statute that no appeal would be heard absent. >> gonzalez rests on a special rule that applies with respect to one arbuckle three court to another theory that explains

gonzalez and those before it. you have five unanimous opinions in the decade in which you have strongly done in the other direction on what counts as jurisdiction all. islamic there's an argument we should say they don't need appeals. estimate you came very close. in henderson, justice, you said that it is explained by the special rules and understanding the governing appeals from one arbuckle three court to another and you specifically said that it does not apply to situations involving the party seeking the initial judicial review of the agency action which is what we have here. one elihu are right the tax are not different they are explained by the principal under henderson that doesn't apply to this case

they speak to the suit, the cause of action it doesn't speak to the jurisdiction power of the court it is placed in a section of the tax code governing procedure. it's not placed -- >> council, all of that in particular -- >> you did rely on that. >> another consideration that is in our favor is the presence of the exceptions. he said three went against the jurisdictional characterization. here there are 11. >> many of them speak in the language. >> some of them have no jurisdictional language at all, and not a single one of them uses the word jurisdiction to describe the ability of the court to restrain the assessment and collection of taxes which is

what one would have expected. >> the difference the land which is relevant, there are a lot of relevant things but one thing that is relevant in my mind is that the taxes are for better or for worse the lifeblood of government. so what converse is trying to do is say there is a procedure to go through. you get your money back and go to the tax court but don't do this in advance for the reason we don't want 500 federal judges substituting their idea of what is a proper and equitable defense when there should be an exception made for the basic role. you try to apply that in the copyright, you can't find it. registration with the copyright registry isn't the lifeblood of any amendment. it exists regardless, so the reasoning isn't there. the language -- i see the

similarity of language. but it's the reasoning that's the sort of underlying reason for not wanting a waiver that has a significant role in my mind of finding plus the fact we set it nonstop whatever the other case is. >> as to the reasoning, you've given the argument ... as it was a matter it might make sense to have been on jurisdictional statute. but time and again congress has to clearly a great the statute as long jurisdictional as what the text and structure and it seems the general appealed to the statutory policy doesn't speak with sufficient clarity. >> as to the policy, i think

that it's the reputation of the view and that in most cases the government doesn't want and congress doesn't want people coming into court and shows there may be some cases including for instance constitutional challenges to a landmark federal statutes where the government decides that its revenue raising purposes are better served by allowing a party to come into court and weaving its defense. that's what the solicitor general did in davis and the court accepted that weaver. for the prior cases, we have the holding in davis and all of the equitable exception when cases. >> so why don't we say it's a jurisdictional except -- >> why would that not promote the congress policies or the

congress explicitly? >> it's a jurisdictional except when the solicitor general wade said. >> i don't disagree. it is a contradiction in terms of the cases analyze the situation as if a statute is jurisdictional the nets not subject to waiver. if you were to construe this as such a one off uniques statute it seems to me we would still win because the solicitor general with full knowledge of the injunction act argument available to him affirmatively gave it up. this is and where he feels to make an argument. was to mcveigh know what it is and not only are they not pursuing it here they are affirmatively pursuing an argument on the other side. >> if you are in the position when we are talking about the jurisdiction of the court

statute passed to stay its jurisdictional to the jurisdictional. >> i wouldn't go quite that far. it has to say that or be directed to the court which is the formulation you have used in your case and which is the formulation the congress used in the tax injunction act that isn't used in this statute. estimate by suppose one could make the distinction between this case by focusing on the difference between institute in something and main ta sub-saharan so it is more with a litigant does and maintaining to dismiss as what a judge does. >> i don't think we have an adversarial system of income was three on the parties maintain their lawsuit i think is the more natural way of thinking of it. >> if i could turn to the merits

question before my time runs out the purpose of the lawsuit is to challenge a requirement, a federal requirement to buy health insurance, that requirement itself is not a tax cut and for that reason alone we think the antiinjunction act doesn't apply, what the amicus effectively seeks to do is extend the act not just to the taxes which is how the statute is written but to the free standing on her tax legal duties >> of the whole point of the suit is to the collection of penalties, taxes, present the taxes, but the idea that the mandate is something separate anyone to call the penalty or text doesn't seem to make much sense. >> it's entirely separate but the explant to use the six

>> it's a command. nothing behind the command about what happens if you don't file the mandate and the answer is nothing. it seems very artificial to separate the punishment for the crime. >> i'm not sure the answer is nothing but even assuming that it were nothing it seems to me there is a difference between what a law requires and what enforcement consequences have been. the statute was deliberately written to separate mandate from a penalty in several different ways. they are put in separate sections. the mandate is described as a legal requirement, no fewer than 20 times three times in the operative text and in the findings it's imposed through the use. the requirement is well defined in the statute, so it can't be sloughed off as a general exhortation and it's backed up

by a penalty. congress then separated out the mandate exceptions from the penalty exceptions and defined one category of people not subject to the mandate. one would think those are the category of people as to whom congress is saying you need not follow the law. and then define a separate category of people not subject to the penalty but subject to the mandate. i don't know what that mean other than -- >> why would you have a requirement that is completely toothless? >> by the insurance or else what? or else nothing. >> because they could reasonably think that at least some people will follow along precisely because it is law and let me give you an example of one category and that might be the very poor who are exempt from the penalty but subject from the mandate he says this must be a

mandate exemption because it would be harsh and unreasonable for the congress to expect people that are very poor to comply with the requirement to obtain a of insurance when they have no means of doing so. that gets things backwards. the very core are the people the congress would be most concerned about with respect to the mandate to the extent one of the justifications for the mandate is to present emergency room cost shifting when people receive uncompensated care so they would have had good reason to make the very poor subject to the mandate and then they didn't do it in a draconian way. they gave the very poor the means of complying with the mandate, and that is through the medicaid system. semidey you think a person that is subject to the mandate but not to the penalty would have

standing? >> yes, i think that person would because that person is injured by compliance with the mandate. estimate what the argument be as to what the injury was? >> when that person is subject to the mandate that person is required to purchase health insurance. that is a forest acquisition and a classic pocketbook injury but even if i'm wrong about that question, justice, the question of who has standing to bring the challenge that we seek to bring seems to be very different. in your hypothetical is different from the actual plan tiffs. we have individuals that are planning for the compliance in order to avoid the penalty which is what the affidavit says and we have to be state who will be subject to the adverse ramifications if they refuse to enroll in medicaid the people forced in medicare by

representative so we don't have the problem of no adverse consequences in the case. we have the distinction between the question of whom has article 3 standing in order to maintain the sood and the question of who was subject to the obligation, and you said in your case is that even if you are making no one that has standing to challenge the legal obligation might be incompatibility or something. i guess it is to convert the legal obligation in to the legal nullity. finally with respect to the states, even if we are wrong about everything said so far, the states clearly fall within the exception recognized and south carolina. they are injured by the mandate because the mandate forces 6 million new people on to the medicaid will but they are not decrease object to the mandate nor could they violate the

mandate and incur a penalty when the state see the dillinger injured, are they talking about the people that are eligible now and are they also talking about people who will become mainly eligible? >> it's people who will enroll, people who would not have enrolled had they not been given a voluntary choice. >> but who are eligible now? >> that's the largest category. fighting fear could be future eligibles who would enroll because they are subject to the legal obligation that wouldn't have enrolled deutsch and the choice. but i'm happy to focus on currently eligible people that haven't enrolled in medicaid. that particular class is the one that gives rise to simply in florida alone a pocket book entry on the order of 500 to $600 million per year. >> that seems odd to see in the

state is being injured because people who could show up tomorrow with or without the flaw would show up in greater numbers presumably the state wants to cover members its declared eligible for this benefit. >> they could but they don't. with the state wants to do is make medicaid available to all who are eligible and choose to obtain it. >> there's a category of people who are medicaid eligible, medicaid doesn't cost them anything. why would they resist enrolling? >> i don't know, justice ginsburg. all i know is the difference between the current enrollees and people who could enroll but have not as i said is a 600 million-dollar dhaka. >> but if they haven't been given sufficient information to understand this is the benefit for them. >> it's possible, but all we are talking about right now is the

standing at the states and the only arguments made against the standing at the states, there is a classic pocketbook injury. the only argument made against the standing of the states are number one, this results from third-party actions. that doesn't work because the third party actions are not unfettered in the sense they are coerced in the sense of benet versus sphere they are enrolling because they are under the obligation to do so. the second argument made against the state standing is the state's somehow forfeit their ability to challenge the constitutionality of the provision of the federal law as they voluntarily choose. >> i am a little bit confused. this is what i am confused about. there is the challenge to the individual mandate. what is the fact the state is dillinger and medicaid.

how does it give the state standing to challenge an obligation that isn't imposed on the state in any way? >> the principal pherae for the state standing is the states are challenging the mandate because the mandate injures them when people are forced to enroll in medicaid. now it is true they are not directly subject the mandate. let me try this way. may i finish a thought? in south carolina the state was not subject to the tax at issue. the state was harmed as the issuer of the bond committee and the bondholders were the ones that were subject to the tax so the state is injured not because it is the direct object of the federal tax, but because of its relationship to the regulated

party has the issue were bondholder a. >> thank you. >> mr. long you have five minutes remaining. stomach everyone agrees that the section penalty shall be assessed and collected in the same manner as to taxes, and the party's principal argument why that does not make the antiinjunction act applicable is that it simply goes to the secretary's activities, and i would simply asked if you look at chapter 63 and 64 of the internal revenue code which is the assessment and collection, they are not just addressed to the secretary, there are many provisions that are addressed to the courts and indeed talk about this interaction that are very limited situations in which the courts are permitted to restrain the assessment and the collection of taxes.

there was a statement made that there aren't -- many of the exceptions in the antiinjunction actor in the provisions. there was a statement made that none of these treacly confer the jurisdiction to restrain the is suspended collection of taxes. that's not true in the footnote 11 of the opening brief. we cite several or simply mentioned 62 as an example. that says and i quote notwithstanding the provisions of section 74218 the making of such assessments at the beginning of the proceedings during the time of the prohibition and forced may be joined by the proceeding in the proper course in the court shall have no jurisdictions to the action or proceeding under the subsection unless a timely petition for the determination of the deficiency has been filed, and then only in respect of the deficiency this the subject of such petitioning.

.. docking to me to

>> they said it is still clearly assessed and collected in the same manner as a penalty and that subchapter, and those penalties are collected in the same manner as taxes. that is -- i think it is rather detailed, but i think it is a rather clear indication of the anti-injunction act applies. the refund statute that does specifically referred to penalties, that has nothing to do with this argument that it is assessed and collected in the same manner as a tax. that would go to the point that you can't just call it a tax because they referred to as a penalty. finally on jurisdiction, i think the key point is we have a long line of this court's decisions that has been ratified by congress with all these

exceptions and jurisdictional terms. as i read the just of those decisions that was a sort of special rule of appeals when they have that situation, what i would submit applies as much to the collection of federal taxes as does to appeal federal district courts. when we have this degree of president, including president from congress in the form of amendments to this anti-injunction act, that should be the presumption -- it should be that this is jurisdictional. no further questions. >> all right, mr. long, you are invited by the court to defend the proposition that the anti-injunction act artless litigation. you have carried out that responsibility for which the court is grateful. we will continue the argument in this case tomorrow. >> the supreme court continues

with oral arguments on healthcare law. tomorrow, the court will consider whether the individual mandate, which were buyers americans to by health insurance or occur penalties will be discussed tomorrow. on wednesday, it will be discussed whether the individual mandate is favorable for the law. and if not, whether the entire law should be invalidated. good afternoon, the justices will hear arguments on whether the extension of medicaid coverage is constitutional. the supreme court will continue to provide same-day audio tomorrow and wednesday. you can hear the oral arguments when they are released, expected around 1:00 p.m. each day and also at four clock pm on wednesday. we will have coverage on c-span three, c-span radio, and on c-span.org when you can listen and answer comments.

on tomorrow morning's washington journal, we continue our look at the healthcare or argument. we will be joined by guests. they will recap monday's arguments and look at the consideration for the individual mandate tomorrow. we will also get perspective on the provisions of constitutionality from a professional of yell law school and a professor at northwestern law school. washington journal airs live every day on c-span. a look at the lineup this evening, x., the efforts to present entry tour brain injury. then efforts to implement mobile phone -based phone technologies. after that, the director of disease controls and prevention gives an update on the aids pandemic. >> in march of

>> the health committee recently held a conference on genetic brain injury. the centers for disease control and prevention says 1.7 million americans sustain a genetic brain injury every year. witnesses called on the federal government to provide more resources for tbi, and government facials who testified described efforts to coordinate tbi programs across area agencies. this is one hour and 20 minutes. >> the chair recognizes for an opening statement. as many of you know, march is brain injury awareness month. according to the cdc, an

estimated 1.7 million people sustained h. or mattock brain injury each year. and of that figure, a 1.365 million, or 80% are treated and released from the emergency room 52,000 will die. tbi affects everyone. it is not restricted to one race, gender or socioeconomic group while children age four and under an adult over the age of 75 are particularly at risk, brain injury affects soldiers, athletes, and even members of congress, like our former colleague gabby giffords. the annual cost of tbi cost billions of dollars. but this is not paint a complete picture of the scope of these

injuries. it is not take into account the suffering of a% with a brain injury who may be disabled for life, or the strain of a loved one's that tbi places on family members who are so often the caregivers. efforts begin with the tremendous brain injury act of 1996. the act ain't to identify and increase awareness to renew research and programs. the tbi amendments of 2001 amended the 1996 law, extending the authorization to include the implementation of a national trauma brain injury education and awareness campaign. the dramatic brain injury act of 2000 and eight re- authorize the program. and also authorized cdc in the united states to conduct a study to a examine the information gathered by h. h. s. assess appropriate interventions and discuss guidelines.

i look forward to the results of the study which will come out in november of this year. 2000 and eight and its act also focus on the incidence and prevalence of tbi and linking individuals to support services and academic institutions to conduct research. i would like to hear an assessment from each of our witnesses of these federal programs. what have we learned? about the causes, diagnosis, treatment of tbi through hh a? how has that knowledge been applied in real-world situations? i would like to hear their ideas about where we should go from here. i would like to say a special hello to doctor flora winston from the children's hospital, early they'll be a period it is a wonderful institution who has served many of my constituents. i would also like to welcome those with us today who have tbi, as well as their families and caregivers who make enormous sacrifices every day.

we are all glad that you are here. i yield my time to the vice chairman doctor burgess. >> thank you, chairman, for the record. today's hearing is a vital important, as the cdc indicates that overall 1.7 million people sustain a brain annually. of those who do survive, 11,000 are children. this makes traumatic brain injury the number one cause of death for children. there exist no viable reparative or therapeutic options for patients, and all of the integrations apart design to prevent progression of the injury or secondary injury. in order to successfully treat traumatic brain injury, we must equip healthcare and professionals or resources needed to achieve the goal with improving outcomes and quality of life for those affected. although there are numerous

research projects underway across the country, including the university of texas and north texas brain injury model system, a tbi center, centralize and organize research approaches that avoid duplication is lacking. government accountability releases january a report that talks about traumatic brain injury activities, it emphasized the need for coordination of terror and coronation of services in traumatic brain injury in patients in department of defense. there were conducting their research, there was no central location to obtain accurate and timely information on traumatic brain injury, and they had to use a variety of resources to obtain their data. i believe we will not achieve our goals to better coordinate research and support services if we don't do grasp, this hearing is designed to do that on funding and project -- products that are meant to address traumatic brain injury. hr 2600 would lead state centers like the center for brain health at the university of texas at

dallas, the countries lead virtual center category for teacher at it traumatic brain injury, to continue system based systems of care. eventually the money will be allocated from the discretionary funds and be on hand to advance our knowledge of the brain over the next several years. thank you, mr. chairman for the recognition. i yield back my time to we now recognize the ranking member of the subcommitteefor five minutes. >> think you, mr. chairman. today this can he will have the opportunity to hear from some of the experts in the traumatic brain injury community and an update on the current landscape of traumatic brain injury prevention research and treatment. as we all know, traumatic brain injury is a very serious disease that can have devastating outcomes. when i was chairman of the subcommittee, we held a hearing regarding petri attic sports-related concussions in new jersey, and today i look forward to an informative

hearing and taking voter perspective on this glacier. according to the cdc, over 1.7 million people are subjected to a dramatic brain injury. furthermore, this accounts for one third of all injury related deaths. these statistics are only telling part of the story. it is currently unclear how many people are misdiagnosed don't receive treatment after a traumatic brain injury. traumatic brain injury also affects many affected of our population. it continues to plague our young people and elderly, some of the most honorable members of our society. traumatic brain injury also has a profound impact on our military and sports community. in addition, i would be remiss, if my german said. if a member of our own body, gabby giffords, also had a genetic brain injury while performing her duties. we must prioritize this issue in our prevention and research efforts. it is my understanding that the overwhelming majority of people that cover a traumatic brain injury do not dive from the injury. however, that also means that

these patients are at risk of building long-term complications that can develop from an even mild traumatic brain injury. patients can suffer from cognitive impairments like memory loss, impaired communication, mental honest, apple at sea, and are even at risk of developing parkinson's disease or alzheimer's disease. these complications great this ability and hinder individual's productivity. it also creates an emotional and financial burden to families and society as a whole. ensuring that these patients have access to innovative and vital treatments and social services is a great challenge that we must all work together to achieve. since the passage of the traumatic brain injury act of 1996 and subsequent reauthorization, several federal agencies have led efforts to understand, prevent and treat traumatic brain injury. most recently, they have undergone full formal coordination through that adult interagency committee on traumatic brain injury. this committee, which includes

hh s. at agencies and non-hhs agencies will accelerate and coordinate the initiative. i look forward to hearing more about the proposed tram and initiative. i like a also identified this important cause. >> mr. ditto is a retired director of the new jersey traumatic brain injury program, and also represents the national association or traumatic brain injury ministers. mr. ditto has made great strides to coordinate and provide services for individuals with traumatic brain injury. strengthening partnerships like these will improve the outcomes of the family in patients affected by traumatic brain injury. i look forward to today's testimony. mr. chairman, i would like to ask, as i think you know, congressman pascoe has really been a leader on this whole

issue. i know that he is not a member of the committee, but he asked if i could by unanimous consent to include his statements for the record. >> without objector, so ordered. >> make you, mr. chairman, i look for forward to the testimony and appreciate you have helped today. thank you. >> sure, ladies and gentlemen. i now recognize mr. upton for a statement. >> thank you, mr. chairman. according to a recent report from the cdc, at least 1.7 million folks sustaining a traumatic brain injury every year. we don't have to look very far to see the profound effects of a major tbi. children injured by caretakers or car accidents, athletes impaired by multiple concussions, soldiers disabled for more and even one of our colleagues wounded at a constituent event in arizona last year. with efforts being undertaken at the department of veterans affairs, the department of defense and several agencies and

hhs, it is incumbent upon us to at examined the activities so they can work and coordinate in an efficient manner. i proudly served on the injury task force and encourage bipartisan support for tbi research and rehabilitation. without support, incompetent the committee will make even greater strides to help patients living with the aftermath of tbi. i want to extend a warm welcome to families attending today for brain injury awareness month. i look forward to the testimony today. i yield back to the chairman. >> thank you, ladies and women. today we have four witnesses on our panel. doctor bonnie strickland, director, division of services for children with special health-care needs. u.s. department of health and human services. mr. william ditto, director of the new jersey tbi division, new jersey department of health. doctor flora winston, children's

hospital, philadelphia, and doctor mark ashley, president centre for neuro skills. you are testimony will be made part of the record. lisa marries your statements in five minutes. doctor stricklin, please make your opening statement. >> german pits, make ranking member paloma, to give her the opportunity to testify today on the department of health and human services traumatic brain injury program. i am doctor bonnie strickland, director of the division of services for children with natural healthcare needs at the health and services administration at that department of health and human services. we appreciate your interest in our work and on this opportunity to discuss our tbi program with you and providing highlights of other hhs activities. congress helped implement this program to improve access to

rehabilitation and other services. the cdc has responsibility for prevention and surveillance. there is also another group that provides services. the program consists of two distinct grant programs. state grant program and advocacy grant. the partnership grant our request to have a needs and resources assessment and a comprehensive a wide action plan. with these tools, states have made remarkable progress in increasing access to tbi support, programs, training health professionals, and service ordination. the advocacy programs provide legally based services to help assist and understand laws to help self advocacy. add a scsi helps tbi and their families to make sure they can preserve needed services even if

representation is not available. nih has primarily been response will for tbi research. the prep explains the problem that it presents. both immediately and in the aftermath of the injury. for example, it studies the mechanism of damage, critical trial and research and recovery. nih also leads a broad range of research related to tbi redelegation for the elderly and his orders that coworker, such as poster accessed disorder. cdc is responsible for prevention and surveillance. the agency disseminates evidence on tbi educational materials, clinical guidelines, policies, activities, such as the heads-up initiative, and educates community based organizations on shaken baby syndrome. the cdc also worked with experts to produce the field triage

guidelines which provides uniform standards for emergency medical providers and first responders to ensure that patients with tbi are taken to hospitals best suited to address their particular injuries. santa maintains strong partnerships with the this is primarily a >> additionally, santa has developed materials to encounter and investments or service members with tbi. integrate, there was the first meeting on germanic brain injury. in order to facilitate collaboration and collaboration

>> the current representative from the committee and the departments of defense and veterans affairs, the social security ministration, and with an hhs, it helps with cdc, samsa and traumatic brain injury. cdc surveillance may identify abnormally high incidence of tbi and child athletes. they may develop educational material as well. the cdc uses material to conduct a statewide education campaign for appearance, student, in schools about the risks and consequences of traumatic brain injury. the cdc may utilize a protocol that was formalized by nih research to develop a training program. in addition to education and screening, it connects students with resources.

programs like these allow us to leverage resources to other agencies to identify and help children with with or at risk with tbi. we are committed to ensuring folks with tbi receive appropriate services and support, nih, cdc, and samsa are making strides in the respective areas of research, prevention, and surveillance, and behavior help. we are working together to ensure that our efforts are come from entry and to achieve cross departmental collaboration and strategic use of resources to address a full spectrum of needs of people and families. this completes my remarks. thank you for the opportunity to testify today and provide information about tbi program's. >> we recognize mr. ditto for five minutes for their opening statement. >> thank you, very much. thank you mr. chairman and

ranking member blown. just a quick thing about my position, i am the retired director of disability services of the new jersey disability services. i was given a variety of titles when i was introduced. i'm not here today and that role, but more in my role as the chair of the public policy committee for the national association of state head injury administrator, better known as nashe. we are the only agency that represents government agencies and services who are involved in the provision of short and long-term rehabilitation and community services for individuals with tbi and their families. i am pleased to give you an opportunity to understand where state government stands with regards to serving these individuals. the big item here that i want to

emphasize is that no two individuals with tbi are the same and neither are any two states the same with regards to the extent that they are able to address the needs are in one thing that is the common threat to this country is that brain injury is in fact the leading cause of disability. not only in the state of new jersey, but all across the country. i think this is not being recognized well. if you bought on the street and ask folks what is the most significant disability, we have mental retardation, several policy, autism, all sorts of different things. but in truth, it is, in fact, head injury. head injury is such a disability because it is cradle to grave. it affects people in all age categories. as a result, individuals with this type of disability have to interface with a lot of different governmental programs over their time as a survivor of brain injury.

as someone on the panel has already mentioned, individuals with brain injuries are, in fact, surviving. they are thriving to the extent that they can get services that they need. in the early 1980s, families began advocating for state to provide relocation and other services. there are so many different needs for people with brain injury. there really are no two individuals with brain injuries who are just the same. we also have the mild, moderate, and severe classification of brain injury, which makes it, in my experience, a little less clear-cut. in many other forms of disability, we can clearly state what the extent of the disability is through clinical observation and mental evaluation. this is not true with brain injury. not only back, but there was, for a long time, a feeling that people with brain injury could

only achieve a certain plateau, a certain level, and nothing would happen after that. research has proven that individuals even 10 years post- brain injury can make significant improvements when given the right services. about 20 states have administrative community and home-based service programs for individuals with disabilities that are intended to provide services in blue of a more expensive institutional or long-term care. what our big concern at this point is that the systems need to be coordinated and they need to be available to people of all ages. we have found from the cdc who has moved brain injury up to the top of its list of concerns, when it was not always at the top of its list, we have found from then that the leading cause right now is false. false over the individuals --

individuals who are older, and children younger than four. people suffering from brain injury has throughout the progression of light. it happens throughout the progression of life. it is not just the typical young adult male crash victim or the returning servicemember. it is really a large number of people. individuals with brain injuries and their families are specifically looking to states for help and support. we would propose in terms of the federal tbi grants program, that the grants be shifted away from short-term projects that states are given additional flex ability to use funds for case management and other services. that states can target a grant request which they identify as underserved, and that the program moved from a competitive grant program to a formula

funded approach, contingent upon the availability of federal funds. that way it allows each state to receive a protectable amount of funding. right now, but program is competitive in funding. twenty-one states are receiving grants. the rest of the states are not receiving grants. they are relying totally on their own resources to be able to do that. just as states are required to coordinate and maximize state and federal programs and resources, we support the national interagency task force to progressed federal resources. we look forward to the time when the task force will invite stakeholders such as the brain injury association of america, the national disability rights network, as well as individual tbi and their families to write input as we develop a plan a priority for tbi. thank you. >> chairman, we recognize doctor winston's for five minutes.

>> good afternoon. thank you chairman upton, chairman pits, vice chair burgess, ranking member blown, and distinguished members of the subcommittee for calling this hearing and inviting me to testify. i'm encouraged to see the increased focus on tbi, along with the emergency care and prevention. my name is doctor flora winston. i serve as scientific director for the center for research and prevention at the children's hospital of philadelphia, as well as professor of pediatrics of the university of pennsylvania. in addition to be a doctor trained bioengineer, i am a board-certified practicing pediatrician and a public health researcher. the children's hospital of philadelphia is the nations largest pediatric research programs in the u.s. i am humbled by the commitment and skill the hospital brings to pediatric injury, much of which has been enabled by investments

by the federal government. i came to care about tbi early in my training. when i would hear the transport helicopter, i felt a sense of dread for the family whose life would be changed by their child's tbi. everyday, more than 125 of our nations children are hospitalized or die for tbi. car crashes, sports, and other causes cause tbi. anyway, tbi costs more than $29 billion for children who died, and $53 billion for those who are hospitalized. therefore, the nation, i propose that our primary success metric should be annual reduction in genetic brain injury. to reduce the tbi burden, i propose three priority areas. one, prevention, to, timely state-of-the-art acute care.

and three, optimal recovery. i hope to demonstrate the importance in research, professional training, and coordinated effort. together we can address childhood tbi so that her children and grandchildren can reach their full potential. the good news is that we know how to avoid tbi. protect the brain from blows and jolts. prevention is the best medicine. if you get your grandson into a car seat or your daughter to the hospital in time, you can reduce the chances of tbi. unfortunately, many strategies were designed for adults, not for children. let me demonstrate how we can do better. we found that cars designed to save adults can fatally injure a child. research supported efforts by government and industry to improve air bag design, policy and education.

now, airbag deaths are rare. successes like these require strong science and collaboration. the national science foundation has provided us with the opportunity to work with partners to protect our children's brains and a world designed for adults. research funded by nih, cdc, tran-three and cdc taught us another lesson. when it comes to tbi, child age affects the brain's response to impact and recovery. for example, we now know the instance with severe tbi has the worst prognosis. when compared to adults, older children with mild tbi recover more slowly with more physical, emotional, and cognitive challenges. federal funded by a mechanic by a mechanic research helps. tbi will continue. our next level is timely and

acute care. over the past decade, the cdc has raised awareness about early recognition response to tbi. children with severe tbi require highly specialized aggressive care in the hours after impact. driven with more mild tbi require cognitive and physical rest within the first 48 hours. federal investments and basic and translational research are leading to improve strategies for those on the front line, and i suggest taking this to the next step by including industry and our partnership. unfortunately, the reality is that there are limits to current prevention and treatment. this is why recovery is our third line of defense. one of the 15 children who suffered a tbi today could have been your child or mine. they now face a long road ahead to recovery we need to be

empowered with the best tools to restore vital cognitive function and help our loved ones recover fully. hhs funding enabled partnerships between schools and clinicians. easy to continue. i want to look forward. recently, i was selected as a hero by elementary children because i worked to save lives. they, too, want to save lives. but i worry that their dreams may be stunted. we need to shore up the necessary training and funding opportunities that young people need to become investigators, investors, innovators, and clinicians for pediatric injury. mr. chairman, ranking member, and members of the subcommittee, as policy members, please know that i am grateful for your role in helping to save children's lives. i thank you for inviting me to testify and look forward to answering your questions.

as you consider this issue, i want to leave you with one thought. the average medical cost for children hospitalized for tbi is $40,000. that is a lot. >> we recognize doctor ashley for five minutes for an opening statement. >> good afternoon chairman. >> press your button there. >> there we go. >> good afternoon chairman pits, and ranking member, and members of the subcommittee. thank you for the opportunity to testify today. my name is doctor mark ashley. i'm the president and ceo of of the center for nurse skills which offers brain rehabilitation programs in california and texas. i also serve as the chairman of the great association of america i'm a witch represents the 5.3 million children and adults in the u.s. who have long term long-term disability as a result of genetic brain injury.

in 1972, my brother steve, sustain a traumatic brain injury while in the navy. for eight years he laid a incompetent, unable to move, unable to speak, communicating through i'd links only. when i completed my professional training in 1980, i cofounded the center for narrow skills and admitted my brother. after 18 months after revocation, stever gained cognizance, speech, movement in all and all extremities, and was able to feed himself. i hope to provide you today with several key points. the first is that genetic brain injury affects people of all ages and is more prevalent than new diagnoses of all cancers in the u.s. up to 4000 people a sustain at sustain a brain injury every day in the united states. the injury is heterogeneous and unpredictable. treatment is complex and highly specialized. treatment particularly in postacute settings is clinically

effective and cost efficacious. there is significant variability and access to medical availability and care for traumatic brain injury. tbi is not an event or an outcome. it is a catastrophic condition and the start of lifelong disease causative and accelerated processes. the brain's metabolism stabilizes and improves. this allows the brain to find and use undamaged, alternate pathways to perform tasks, a workaround, if you will. to maximize recovery, the brain must grow new nor ons, new synapses and vascular structures. in short, a new brain. the process is induced and rate limited. it occurs slowly. for children and adolescents,

early recovery gives way to later deficits and behavior, new learning, and skill acquisition. there is not a single pathway or course of treatment of traumatic brain injury. instead, care is provided across east bactrim of settings, including nonhospital based rehabilitation facilities that evolve in response to demands for less costly treatment. when my brother was injured 40 years ago, his initial hospital said was over four months. isn't his treatment initiated eight years later. more recently two people may grow miraculous recoveries after a year or more of rehabilitation. today most people with moderate severe brain injuries averages 19 days in the hospital and just 26 days or less in postacute rehabilitation. what surprises most people is

that today many patients do not receive complete relocation. they include older patients, minorities, those who have no insurance, or who are covered by medicare and medicaid, even many who have insurance. the consequences of this shortsighted approach include medical complications, greater permanent disability, dysfunction, job loss, homelessness, impoverishment, medical indigence, as suicide, and involvement with the criminal justice system. inadequate treatment leads to lost productivity and greater use of medication, durable medical equipment, maintenance programs, and long-term care and institutionalization. in contrast, revocation of sufficient scope, timing, and duration, are well-documented but are not well-known in the general medical community or

among payers, patients, or families. proper acute and postacute treatment and disease management help to restore maximum levels of function, reduce long-term disability, and suffering, rather than merely accommodating for it. my company provides postacute treatments by physicians, license set their bits, and professionals in the living is the least like many other companies. therefore, we are not eligible to be a medicare provider, and because we do not have a medicare provider number, we cannot accept tri- care patients to a normal admissions price process. we are voluntarily supplementing the care paid for by the da with more frequent and intensive airbase. after 32 years of clinical practice, i know that that is what our service members need and firmly believe it is what they deserve. tbi can change how you move,

talk, think and feel. it can change the length of your life and its quality. individuals with brain injury and their loved ones are really able to advocate for themselves. they rely on policy makers to invest wisely in prevention, treatment, and it medically necessary revocation and research. millions of dollars were spent on rain research compared to cancer. given the similarity of incidents and higher oil costs associated with brain injury. brain injury association supports research by the one-minute campaign. investing in an epic teleology at research which supports research for children and adults

by the national institute on disability and rehabilitation research. we cannot sacrifice care while the field works toward it here. therefore, we strongly support reauthorization of the tbi act. we urge policy makers to move away from time-limited projects to provide funding so that all states and territories can address this problem. finally, as you've learned today, administrating treatment at the proper and time with the right scope and intensity and duration by a well skilled workforce yields significant cost savings in both the public and private sectors, and vastly improves outcomes, functional independence, and life satisfaction. we hope you will take action leading to better health, enhanced and women, and education and more fairness and equality for this population. thank you. >> thank you, gentlemen. thank you all for your opening statements. we will now -- we will begin the questioning and i recognize myself. doctor strickland, the committee

applauds your efforts to convene an interagency working group to maximize resources and coordinate federal efforts related to genetic brain injury. would you please review the goals of the working group and what is the role of the stakeholders within the group and how do they receive public input? >> thank you. the purpose of the federal interagency quarter naming counsel, it is, as i said in my testimony, to facilitate greater collaboration and coordination across the agencies that are working on tbi activities. we want to maximize the activities and we want to minimize duplication of effort. we also want to create a common vision across the multiple programs that are going on, not only in hhs but across

government. we want to collaborate and leverage each other's resources. one of the ways that we are doing that is through a clearing house of federal -- federal tools. we are hoping, and we are just filling this out now, we are hoping that we will be able to include tools produced by all of the federal programs in one place that would be extensible to the public and to each other, so that we would not duplicate efforts and we could use our scarce resources to launch out into the area. >> thank you, doctor winston. we have always heard of the plasticity of young brains and their ability to adapt to the surgical removal of parts of the brain. yet, in your testimony, you mentioned that young brains are actually harmed more than the

brains of older individuals, would you elaborate on this difference? >> guess. children differ from adults by a mechanically, socially, and these differences affect injury and its recovery. just think about normal children and the amazing changes that occur as your children grow up. think about when you held your baby. think about when you cut your older child had arrived a bike or tighter teenager how to drive. just as they are different on the outside, their brains are different on the inside. new research is showing that this fundamental knowledge of the brain and its response to injury is yielding some surprises. we used to think that children were more resilient -- their brains were more resilient to impact. but, in fact, let me give you three examples. an adult skull fractures on

impact. if it's goals and. when it ends, it presses on the brain. infants have stiffer brains. we used to think that was protective, but in fact, they injure at much lower levels of impact and energy. finally, some new research that was done by the -- the first research was done by a lady at the diversity of pennsylvania. it shows that for mild genetic brain injury, we start to see that their disabilities emerge that might not have been thought to be the case. here there is a slight difference. it is the teenagers who have more disability from the same level of mild traumatic brain injury. i think that this really shows that we are just beginning to truly understand the mechanics of brains, the biology of what

happens in the event of an injury, and this knowledge and this furthering of our understanding of the scientific foundation. it will help us to come out with better prevention strategies, therapies, and i hope, better recovery. >> you mentioned the short-term and long-term effects of brain injury in children. can you have long-term effects without noticing any short-term injury? >> you usually will see something early on, but there are some subtle differences. children are continuing to develop as we go forward. i often talk about children as an unfinished painting. we don't know whether they are going to go or what their potential will be. as they get older, there might be a need for certain cognitive ability. there was a study that was recently done that showed that 36 months after germanic brain injury, children with moderate

to severe brain injury had much poorer function than they did at baseline, and that they had no improvement between 24 and 36 months. this really gives us pause that we don't know enough about how to optimize their p. and recovery, but we do need this in order to better inform our future interventions. >> we recognize ranking member senator pong for questions. >> i want to start with mr. ditto. it is my understanding that the treatment for a brain injury is complex. unlike other diseases, has to be tailored for each individual, and i realize there's a great importance in and interdisciplinary approach and management of medication. diseases may require a broad range of services including education, location, rehab,

housing, and state health departments like yours play critical roles in serving as an access point of care. can you tell us more of an inch entered the senate interdisciplinary approach. can you highlight the way that new jersey department of health has moved toward? >> of course. i do want to say that is very true that one of the most cripple services for individuals with brain injury, regardless of the age at which the brain injury occurred, is the ability to get service coordination and altai disciplinary intervention into the picture. it requires a lot of different oaks with a lot of different specialties to be able to help people.

no two people are alike. when we look at this, the importance and important element is to have one central coordinating individual, that is usually the case manager, that the family and the individual can work with to structure the kind of individualized service package, and then follow along. case management is a non-successful program it if you just ate a need to go to someone on monday and wednesday. maybe you need to go there with them the first time, not only tell them about that. maybe the follow-up, may be, maybe you need to check with the program to see if their attendance has dropped off. you need to have someone who is measuring progress. case managers look at where they start with their clients and they move forward. case management can come from a variety of sources. the title v maternal and child health program provides states with funds to provide case management to children with diseases and disabilities, and i

can tell you in the state of new jersey the highly effective program that works very well in terms of providing that level of intervention, helping families negotiate. it is harder in the adult system for us to offer those kinds of services because there are not entitlement programs that we can turn to. for the individual with an adult onset brain injury, states have developed things like state trust funds, we did that in new jersey, a surcharge on motor vehicle registrations. we did that in new jersey, we reregister our cars every year. we have to pay for. we got them to take a dollar of that and put it aside into a trust fund, and we used that trust fund money to help support education outreach awareness and direct services. the most requested service in the state of new jersey by people of all ages from children

through 99-year-old people was case management. someone to help them negotiate and navigate the system. and somebody with sufficient training to be able to understand the subtle differences between people with brain injury. if you see someone who has had a severe brain injury and there in a wheelchair, you august the 80 that they have physical impacts from it and that so often for people with brain injury, they don't look any different than you and i do. but they have the problem of cognitive dysfunction. they have the problems of impulsivity, aggressiveness, they have the impaired process that leads to social problems. one of the things states are very concerned about is a lot of individuals who have brain injuries and up in our justice system. they end up in our prisons. i hate to tell you, but it is true, they end up in its state

psychiatric hospitals. that is not a place for an individual with a brain injury to be. i've spent a good deal of my time in my professional career trying to get people out of inappropriate places. but the funding for this is very difficult. there is more funding available on the child's side than there is on the adult side. we are trying to tap into the aging piece of this and get more help from the administration on aging, but it comes back to the issue of really seeing that this is a lifelong disability that impacts people of all ages. we have to look carefully what has artie then been put in place that we can knit together to provide a comprehensive service. even if we cannot afford the treatment for everyone, at least if we can give them case management services and get someone to help coordinate their care with their rehabilitation

care with their education programs, with community supports and services to make a chairman if difference. again, when i say that i look at our funds in new jersey, which was successful, the most frequently requested service was case management beyond all others. we offered a very broad range of health modifications and treatment services and all sorts of things and people opted for the thing -- the thing that was most opted for was case management. that is not equal across the country. you go from state to state, and that is the luxury of working in a national organization like i do. when you go from state to state, there is such a big variation in what is available to people. really, this is a lifelong disability for which people, in my view, and i know not everyone likes this term, but they survive. i am not sure that they recover. they survive, they learn compensatory strategies.

they learn how to make their way and improve their social interaction and minimize, hopefully, their involvement with the legal system. it is a lifelong disability. you don't wake up one day and say oh, i don't have a brain injury any longer and everything is normal and i'm fine. is there forever. >> thank you. >> we recognize the vice chairman doctor burgess request and. >> thank you. doctor winston, along that line, do you have a sense as how states are doing things differently among the states. you have a sense as to whether or not there is coordination at the state level as to adopting best practices, what is working in one location might be transferable to another location. is there communication along these lines. our states looking at what programs are working in other areas and then i would like to go to doctor strickland as to

what the federal side of that is. other states that are doing it right and states that show for improvement? >> i have to say that it is not my expertise to look at what states are doing, so i can't give you a full answer. i can speak to one program that was funded in pennsylvania. it might be of help to you. in pennsylvania, there is a program that is called brain stats to try to reintegrate children into the school system. understand that that is the job of children, to go to school and get back there. now, every school district in pennsylvania has been trained in dramatic brain injury and there is coordination between the school districts and the local healthcare teams. i think that there are some models. i was hearing from the panel members here. we need to build the collaboration, and again, i want

to reiterate that it is not just within the public sector. it is also with the private sector. it is really important to keep them together. i would like to actually give my time over to doctor strickland. >> one follow-up before we leave. what type of coordination do you see between the schools and department of education in this regard. optically, the schools may become the de facto revocation signer for children with brain injury. how do they integrate with the state department, education or the federal department of education? >> i can tell you that one of the main things i do for children as a practicing pediatrician, is to try to get them into an individualized educational plan, to give them the medical care that they need at the school, and this does require a