there they are not very good to talk with one another. . . everything that we can to bridge those gaps and to make sure that folks understand that public health and public safety are incredibly intertwined. with that, ed, i'll go to the folks to your right. >> terrific. thanks very much, steve. could i just ask you one question? >> sure. >> you were talking about new terms. i'll tell you one new term i would appreciate your defining. that is criminogenic. >> sure. what we now know is we now have identified the causes of behavior that result in people gaving in a criminal justice manner, the people becoming justice involved. those come under the general heading of criminogenic. that means the characteristics that have way more to do with mental health, housing, lifestyle, anger management, they have to do with peer relationships, that there's this whole bevy that we know now how

to treat. the challenge has been the regulatory framework in a post-affordable care act world that limits our treatment. i want to make it clear that this is a bipartisan issue. governor perry, governor deal of georgia, they've been going out and promoting treatment of criminogen criminogenic behavior rather than incarceration. what changes is states who have enrolled in the affordable care act is to scale this at a level a state governor cannot necessarily do. >> thank you very much. we'll turn next to debra rowe. >> thank you, ed. all right. good afternoon. during my i witnessed the disheartening maltreatment of women who were ill and resided in my dorm. for example, the women who were sick we are kept at the very end of the dorm. this was during the time when h.i.v. and a.i.d.s. became prevalent in communities and several of the women that i am

referencing had h.i.v. infections. during that period, i met my colleague here, jacqueline, you see, we, along with a few other sisters, were the voice for those women. we raised cane to force the correctional officers to get off of their behind and get them to the infirmary when needed, and we bathed and fed them ourselves. upon release, i was offered a job by the d.c. department of corrections health administration to educate my inmate and re-entry peers about h.i.v. i read a report from the centers for disease control that stated that 16% those of entering d.c. jails had h.i.v. infection, and i wondered how they knew that, and i began my personal inquiry because i knew that h.i.v. testing was not being offered at that time. i'm going to rein tour out and -- venture out and say they were blind-testing these inmates

and after advocating for testing in the jail, the correctional medical staff was frantic they didn't have the resources for the testing which confirmed my suspicion about the blind side. i see the same parallel with hepatitis~c and that many men and women, who who have served ten years or more or less who have had blood d.a. draws contracted help -- hepc until they went to a doctor. one inmade who served 15 years in prison went from louisberg to cumberland, and enpetersberg and had blood draws upon entry to each of those institutions, yet he did not learn of his hep-c diagnosis until he was tested at a community clinic upon his

release. according to the centers for disease control the prevalence of hep-c in prison inmates is substantially higher than the citizen population. 12 to 35% of chronically infected compared to 1.5% in encitizennallized u.s. population. -- ininstitutionallized u.s. population. it's part of a history of injection drug use. cdc recommends that correctional facilities ask inmates questions about their risk factors for hep-c infection during their entry evaluation. reported risk factors should be testifiesed and those who test positive should receive further medical evaluation to determine if they have chronic infection or liver disease. although it's not exclusively considered a sexually

transmitted disease, the hep-c virus has the potential to be spread through sexual contact. it shouldn't matter they are incarcerated. they have the right to know. all of this is happening in the private prison. and in closing, the inmates have reported that the health services are limited and they're being charged. they have to pay $5 to sign up for medications and you can pay and sign up to see a dentist, for example, and may not see him until the following year. one inmate told me two days ago he had an abscess that swelled up to the size of a baseball after three weeks before he was treated. i'm passionately concerned about those who are 55 and older in this system. this concludes my story and i'm happy to answer any questions,

and i do concur with all of these recommendations. thank you. >> thank you very much, debra, and of course, for those of you who haven't been reading health policy stories for the last year or so, hep-c at a thousand dollars a pill, has a cure, and prison systems and other correctional facilities right now are having to figure out how to deal with the kinds of percentages and numbers of inmates and residents that debra was talking about. , so public help meets correctional policy. now, turn to jacqueline craig-bay. thank you for being here. >> thank you for having me. my name is jacqueline craig-bay, and i am a former inmate.

i have several stories from when i was incarcerated. as it relates to the medical in run. -- in prison. while i was there i broke any leg, and it took them approximately a week before they got me to the hospital. i was taken to the infirmary there in the jail, and they put a makeshift cast on. it was just put on with no padding, no anything. i don't even know if the lady had a license to put this thing on me. but when i finally got to the hospital a week later, the doctors over there laughed bat and it called one another and come to see this funny thing that was on my foot. and the medical facility just

isn't a place where inmates should be. nobody there is actually looking to take care of an inmate. it's just a job to them and they're just there for the paycheck. when i was pregnant, i had a child while i was incarcerated. and after i had my child, women here know that you have to have a six-week checkup after having a child. well, i saw the doctor in the hallway, and he just touched my stomach and said, you're fine and that was my six weeks checkup. and these are the type of things that go on in the prison, and are not talked about. nobody talks about the people who have h.i.v. and they're afraid for other people to know they have h.i.v. so they don't go to the medical facility to get their medications. they don't want people to know

their status. so, these are people who are sitting there with this disease and not being treated. they don't have the staff to talk to these women and men to let them know that it's okay to come to the infirmary, or some kind of way to give them this medicine without everybody knowing what the medicine is. because when you go through the line, everybody knows what everybody is taking. so some people don't want to take their medications. and that is a problem. that's a big problem. there should be some kind of way where women or men can get their medication without the world knowing what you're taking. also, i've seen people passed by in prison for things that could have been prevented. women were coming down with

cancer in connecticut, and it was just crazy. it was so many women at one time. coming up with these cancer diagnoses, and before they would take them to a facility to be treated, they sit them there and talk about all these different tests and had they taken them to a facility to be treated before doing all these different tests, then sitting there waiting around, they could have been treated and would have been fine probably. but instead they sat there and waited and waited and waited, and these women died. in prison. and when they got there, nobody said they were -- they had cancer or anything, so they were not tested for these things. but yet they had these different ailments, and nobody in prison cared. nobody cares what goes on with an inmate.

they consider us the forgotten, the ones that nobody cares about. so, we have to care for one another. so, i was call attorneys and people i knew in the district and have them fly to connecticut to help one of the sisters and brothers that needed some help, because otherwise we'll sit there and languish in prison with no help at all, and it's just really sad thing for -- to languish away like that. and that all i have to say today. >> that's quite a lot to have to say. thank you, jacqueline. let me just ask both of you, you have described some conditions that would result in the

issuance of some arrest warrants if they occurred in some other situations, and i wonder, what your perception is of the progress that is being made in the facilities you know about toward addressing some of these shortcomings. there is no progress being made. people are still -- jackie was saying -- how many years ago in connecticut -- >> 2001. >> okay. 2001, women and men are still dying, and family members -- i receive calls from family members that they were just notified that their family member died and they buried them. or they died and they can't give you any answers. are you going to be able to make accommodations for your loved one or not? it's just point blank like that. they're still dying.

all of -- what just talked about, the young man with the abscess, or the people coming home with hepatitis~c and not knowing, or the people that are in there very aisle -- our women -- d.c. gave up the right to our inmates. we were left to be at lawton reformer to during that time but the closed our local prison so all our women are in a medical facility way down in florida. so they're far away from home and they're sick, and at least if they were in their vicinity and -- they're supposed to be in 500-mile radius but they're not. they're all over the country. inmates are spread all over the country. not just speaking for our d.c. inmates, any inmates. i collaborate with a lot of different states on advocacy for

re-entry, but anywhere, the family contact is very important. it's very important that you're able to have contact with your family, especially if they're ill and just like i said, if you blind test people and they don't know, just like cancer, if it's undiagnosed -- look at the people that go to the doctor and tell you, you have six months to live. but that cancer was in your body longer than that. but -- but these are -- they're just -- it's like they're just forgotten because they're locked up. and when they come home, they have what they call the new federal second chance act, because they deserve a second chant. so these long imposed sentences and then you're not going to take care of them. and like i said, you have -- in oklahoma you have a lot of elderly, airat trick people --

geriatric people -- a man came home, he was 70 years old, still on parole. they said i got to get a job. they said i got to get a job. what is he going to do? that used to be your night watchman or something like that. what is he going to do? all we could do is get him some glasses. he didn't get proper treatment for his vision, so my colleague helped him to get glasses. we couldn't help him find work. still, why hold somebody who is 77 and 85 and they're sick and it's very expensive to take care of them so i know that these reforms and they're talking about medicaid and all of that now, but they're going to have to go back and cover a lot of inmates because a lot of our people are suffering in prison. and, and, if you make too much noise about it or your family

calls and advocates you can get put in the hole. and imagine having a toothache and you're in a cell, because you know you need to pace back and forth. any pain, you got to -- you need some type of relief. but you in a cell and agony, in a cell, not infirmary. at least in the infirmary you can lay down and you can -- and you're getting seen and everything. a year to -- and you're paying for it now. you're paying for it. you work and if your family is not sending you money, then you work in a detail so you have money for commissary, but now you pay $5 for this, it's taken out of your money. you're paying for your service but you can't be seen. there's no progress. there is no progress. >> please, can i frame that?

i don't disagree with anything that deb brace saying but i want to frame it. traditionally we send folks to island when they need to be incarcerated. devil's island, rikers island, australia, alcatraz. we always had this approach that folks who were in the justice system should be isolated and kept separate from folks. in that process of keeping folks separate, the kind of experiences that i'm hearing debra, you and jackie describe, are not uncommon. the blessing is we're all in this room, in this very lovely senate chambers, and in this room because we have this bipartisan opportunity to change that. and we have this bipartisan opportunity to change that because we recognize that keeping folks isolated on an island does not make sense in the 21st century, and that we have to figure out how we build bridges, and those bridges are partially electronic medical

records, bridges which we'll be talking about in the second panel. those bridges are partly thinking differently about how we do sentencing for nonviolent, nonsexual offender,s, but the important thing is the pony in this. we're sitting here in this beautiful room in the senate today because there are several hundred of you who are recognizing that public health and public safety are inter2009ed, and managing public safety by keeping folks on an island is not the way we want to good forward. >> pretty good frame. >> we are going to stop at this point and ask if you have questions for any of the panelists who are up here. let me remind you that you can either fill out a card or good to a microphone so that everybody else can hear your question. and if you are part of the twitter-verse, you can use that as a medium to get the question

to us as well. there's another microphone right over here, sir. i'd ask everybody who comes to a microphone to identify themselves and try to keep the question as brief as we can so we can get to the most questions we can. thank you. >> i'm a primary care physician. i have a quick comment about disability. i work for social security disability for a while in baltimore, and very often we could not get prison health records. we had people who were in prison who had no records at all. people in prison we knew they had record about the prisons wouldn't send them and the states wouldn't work terribly hard. shoot be something easy. especially with electronic records. >> debra? >> i want to say now, we have in the district made progress in that area. i used to facilitate a federal

partners meeting. u.s. parole -- the u.s. parole -- with our medical system here, which is unity health care. that's where all of our community health clinics are, and we sat down and we worked it out where all medical records -- because even when the inmate leaves the prison, they have trouble getting their records. so now all of the records follow them. the all go to unity, and they're centrally located in unity, and that's one progress we have made in the district. >> one sentence question. does the work they do in prison -- does that count towards medicare, social security medicare? >> no, it does not. there is a statutory prohibition for medicare paying for any services that are provided --

medicare first but paying for any services provided behind bars. there's also a statutory provision if you're on parole or probation you cannot receive medicare benefit. on the medicaid side, there's something known as the inmate exception, which goes back again to the original finding of medicaid, which states if you're an inmate of a public institution, is the exact statutory language, you cannot receive medicaid benefits at all. so, again, one of the challenges going back to my comment about islands, and what i'm hearing you say is, we need to figure out creatively how we build bridges to those island. obviously medical records is part of it. thinking about bringing standards of care that medicaid brings is another part of it. but at this point we're all very much in the process of understanding. it is not in our benefit to maintain those islands islands e query becomes how to build a bridge. >> if i can just -- i don't in the whether this is something that you have had to grapple with but one of the parts of

your question was whether the work that was being done in prison could be counted ass a quarter that would give you credit toward medicare coverage eventually. >> the answer is, no. >> no. >> the answer is no. >> urban affairs advocate and a few other civil rights law firm. debra, i heard you mention 500-mile law, and we constantly let this government get away with it. we have a law to establish that any d.c. cold offender or d.c. inmate could be moved no more than 500 miles to keep you with your family members and loved ones. notice that while people in the district of columbia do get locked up, most of the time it's because they've been trauma

tied, -- traumaized. and i'm sure miss rowe can understand that. 3,500 return back to the city and 85% goes back within three years so you're celebrating that you made it past three years because it's a resolving door and has been set up for that, for the revolving door end of it. i'm just asking steve and the panel that you can agree with me, in the prison industrial industry, they make a profit off this revolving door so when you don't get proper health care as far mental health care and you have post-traumatic stress disorder, you're coming back to prison and the industry makes a lot of money. they don't spend that money on health care. mental or physical. if you came into the prison system in a private industry and

your pill costs thousand, or 30 pills cost 600, you're not going to get that medication or the treatment you had in another facility or when you were at home because 60% of any profits in the prison system as far as private is concerned is medical and a lot of people have been suffering and are going to suffer more, and then they are allowed to come back out on the street. pointing out to steve, mostly that we do need some -- when you think we need some advocacy and monitoring mainly at private prisons and making sure their discharge plan starts earlier than eight months, because the discharge plan you physically and mentally start getting these people back into health instead of sending them back out on the street, passing on diseases and thinking about new crimes and things another of that nature, because people take drugs

because they've been traumatized in these prisons. so, when -- it creates a criminal because they've been traumatized, don't know how to deal with these mental health illnesses. they have to supply their habit and they're coming to get the citizens when they come home. because have not been treated correctly. so you got worse off than you were before you went in, any system. so i'd like the panel to -- any and all that. thank you. >> i'd like to answer that question by framing it slightly differently. we have propriety tear companies that provide medicaid services all through the united states but those companies are regulated. they have performance measures they need to meet contractually. the challenge with the correctional health system is by and large it's an unregulated industry. and if you have an unregulated industry, then you have the opportunity for both the kind of human suffering that we heard debra and jackie describe, and

the opportunity, sir, that i just heard you describe, and i think again, that's partly where being in this room and this building points to something -- we don't allow in any other sector, spending $8 billion on health care do we allow it to be unregulated? do we allow it to operate without standards, without quality assurance? without any of the things that are statutoriry required? we 2000 leave that under our federal system, we leave that up to states and counties to go ahead and regulate or not regulate as they may see fit. so what i'm hearing you describe is the underlying challenge that the federal system has allowed state and localities to make their own determinations what regulatory or quality assurance framework they'll put down on correctional health, and in many jurisdictions that's very nominal. >> okay, we have two folks at a microphone, and we really need to get to our second panel as

well, so, i would ask you to ask your question and we'll try to get it answered as expeditiously as possible. >> i just -- i'm a pediatrician and worked in correctional health before. i had the privilege of getting a grant, we did outreach to youngsters who were coming out of the juvenile justice system. we got them on medicaid before they were -- or at least at the time they were discharged. we coached parents, we coached the youth, and the two people that really should be given credit is jane adams of -- in kansas who ran the program, and the medicaid director, who was full force behind this, dr. andy ellison was the kansas medicaid director. he was magnificent in getting --

recidivism rate was dropped by 50%, even in the highest risk youth. i'm sorry i don't have a question but i think it's a good model to think about. >> thank you, mary. >> can i go ahead? >> yes go ahead. >> so, linda flowers, aarp, public policy institute. so, in my mind, what i'm -- thank you for this panel. it's been tremendous and very insightful and i'm learning a lot. so, it sounds like there's this cost shifting going on between the federal government while they're in there not paying for the things that people need, and then they get out -- if they're in a federal prison, then they're in a state responsibility, whether or not there's a medicaid expansion or they become disabled or aged and can get on to medicaid that way. so, i'm wondering if -- first there needs to be more data about the amount of money that is not being spent on one end and how that translates into

increased spending at the state level once most of these people get out of prison, which one of your -- i think that could be a powerful tool for states to use to try to leverage some better improvements while people are incarcerated in federal personalities. the other thing is if you can figure out a way to cut the data by state to sort of show to a state the value of doing the medicaid expansion, that you're going to save lot more money on otherren unanticipated costs becauses you made a way for people to have a pathway to health care. also, i wonder if you can talk about any best practices in states working with the federal government and states working together to have a better outcome while people are incarcerated and then when they transition out into a state. i think you can beef this issue

up a whole lot more. >> linda, those efforts are already underway. the federal bureau of prinze just instigated a requirement for standardized release in terms of doing substance abuse disorder evaluation. i think we're starting to see that kind of process come down. on the medicaid expansion side, i think the data i gave you from washington state speaks very loudly to how there's a direct relationship between healthcare spending, recidivism and criminal justice spending. so i don't think it's because of a lack of data that we haven't been able to make that push. i think, again, we have to realize that public health and public safety are enter twined and interconnected and doesn't serve the taxpayer to keep folks on an island without the appropriate regulatory framework we expect as part of our federal, state and local partnerships. so what i would say is the dat is there and we're in the process of the bop trying to implement exactly the kind of thing you're talking about.

what we haven't done yet is made this conceptual leap and that's what we're all here today to talk about. we have not made this conceptual leap that says we need to figure out how to build as many and as sturdy bridges between community and corrections as we can. >> bob, last question. >> bob grits with the institute of social medicine and community health. i remember when senator willford ran for senator from pennsylvania and made a;04ñx$&ñe about prisoners being one of the only populations in the united states that had a right to health care, and in fact that was based on a supreme court decision. how does that precedent not create the political power to implement the kinds of solutions that you're hinting at, and haven't we learned anything from the tuskegee experiment? seems like collecting data and

not using it is a violation of our civil rights. so, where is that -- how does that fit into this problem? >> where are the lawyers? >> right. >> well, there are really several questions. i have to be a nerd here and slightly correct the senator. it's native americans under treaty and incarcerated individuals. the two individuals, america for whom health care is a right and not a privilege in terms of the supreme court case, what the supreme court ruled was that the responsibility of a jurisdiction is to not be deliberately indifferent to the healthcare needs of an individual. so, for example, if you had a lawyer going back to your example, debra, waiting a year to get a dental appointment, that dental appointment was made. i wasn't deliberately indifferent to that person's needs and i go back to regulatory framework, that it if you think about how we do managed care within a minute setting, we require a certain

number of days after which an appointment has to be made. we require a certain level of credentialing in order to provide care. we don't do that in correctional health at this point. we're still on an island and that's the point you'll hear me say over and over again this afternoon. >> all right. i don't want to cut people off but i do want to give us the benefit of our last two panelists. jacqueline, debra, thank you so much, and if you're going to be sticking around anyway, maybe we'll find some stray questions at the end of the q & a for the second panel. thank you so much. >> thank you. [applause] >> i'd ask our second panellesses to come up. -- panelists to come up.

[inaudible question] [inaudible conversations] >> we are reconstituted panel-rise. you heard from steve rosenberg, the other panelists on my right, dr. sharon lewis, the medical direct for your the georgia department of corrections, a board certified pediatrician and nationally respected expert on quality assurance with more than 20 years of experience in health care and managed care, and right now chev is responsible for delivering adequate and cost efficient care to the inmates in the georgia correctional system. next to her is dr. asher tourney, the medical director

for send touran of tennessee -- centurian of tennessee, which which tennessee contracts to provide healthcare services for the correctional system. dr. turny is boar certified in urgent care and special interest in health inequalities and the health of vulnerable workers. welcome to both of you, and i would ask -- i guess we need to pass the clicker to the lady who is next. dr. lewis. >> good afternoon, i'm a board-certified pediatrician so i tell folks that i have 55,000 bad kids under my care. what i'd like to do is to give you an overview of the georgia department of corrections, which i think is a reflection of a lot

of other correctional departments throughout the united states. fortunately we have had lots of success in ill proving healthcare being delivered to inmates in our custody, and fully respect the estell verse gamble ruling with mandated health care. to start out, georgia has a little bit of difference here. we're the ninth largest state in overall population, but with the fifth largest prison population. roughly 55,000 offenders in prison, and about 145,000 probationers. 94% of our population is male and six percent is female and i think this is, again, reflection of other states. the male population unfortunately has a predominant of african-american. 62% of the population is aged 25

to 45 chronologically, and i'll speak more about that. 50% is over 35. so, you think about your general population in the free world and how we mirror what is in the free world. we operate 120 facilities, 31 of those are prisons. we also operate county and private prisons, transitional daycare and day reporting centers, probation detention centers and boot camps, and, again, we're responsible for producing constitutional -- providing constitutional mandated health care. dot everyone understand what that is? it means they're basically three minimal standards. one is that all inmates have the right to access care. secondly, they have the right to care that is ordered. and, thirdly, they have a right to professional opinions of those providers to order that care. such that the example i give is

that -- we can't have a dentist that tries to do an an appendectomy. that the third piece of it. our demographics are such that 37% of the inmate population has significant chronic illness. that number in percent is up after four years. four years ago it was 33%, and every state is challenged with this. where the -- they have an increased cute and chronic diseases and the diseases most prevalent are h.i.v., cardiac, hepatitis~c, mental illness and cancer. 17% of the georgia population receives mental health services, and there's some difference with that. in the female population, 50% of our female population is receiving mental health services. compared to about 12% in the mail -- male population and we think that's attributed to cultural differences and in

female, it's behavior disordered, mood disordered. we have most of our inmates we say con logic aim. the fir age exceeds theronologyic change but a or their lifestyle prior to institutionalizing. they have lack of activity or meaningful activity. minimal to no healthcare, dental or mental, and an accelerated list of chronic diseases. we have an increased population of aged, blind and disabled, and our admission age is older. the average now is 33 years of age, and then it therefore translates into older age of the population which is 36 years. so, we're not getting more young people in that i call, but, rather, the older folks are

starting to come in. in fiscal year 2013, these are some pretty startling statistics for us. those over 35 years of aim are -- represent 54% of our population, and account for 75% of the claims. those that are over 50 years of age are 18% of the population and account for 47% of the claims. but most importantly here is that those that are over 65 represent two percent of our population, but accounts for eight% -- eight percent of the claims so that's a lot of money. those over 65 years of age, their average claim cost is around $3,500, versus those that are less than 65 years of age representing only 591. so that's a dramatic difference just based on the image. -- based on the age. here i like to look at the per

diem budget. over the last at least five years, each year the department of corrections has been given a reduced budget. so, we have this budget that is continuing to be reduced. we have the mandated constitutional health care we have to provide. we are continuously having an intake of chronic illness, which includes those women that come into our pop late progress -- population pregnant and we're responsible for prenatal care and delivery, and they're high risk. so all of the services we're required to provide are -- we're having to get very creative in the strategies that we use in order to provide that necessary mandated health care. the covered population that you see listed below represents the population that is covered in our general population. we have probably about 6,000 inmates who are housed in what we call private prisons.

there are several prisons within our stake -- state and the cost does not come out of our per diem there. so, again, here's our creativity. as you heard i had a long hoyt with managed care organizations and whether you like them or don't or whatever, it's the world we live in, and they are successful. so some of the principles those managed care organizations have used, we have applied to in the department of corrections. the first one being, i'm very proud of this, the summarize healthcare benefits, the same document or similar document you receive when you sign up for your own insurance. basically tell you what is and is not covered and is and is not eligible and basically, what the insurance company will and will not bay for. but for -- pay for. but for us it lists what services are eligible to the inmates and which ones aren't and puts everyone on the same playing field because the

inmates understand what services are going to be covered, which ones will not. and also, the providers of those services understand which services are eligible to give you examples, we don't pay for umbilical heron ya, -- heron ya, cosmetic surgery or acne or mail pattern baldness, your sex change operation. or your sexual activity. so, those are the kinds of services not considered eligible. all other medically necessary services and those are the key words, medically necessary, are provided to the inmates within our custody. they document has been reviewed by the office of the attorney general and provides the framework for constitutional health care. the second foundation is preventive care. i know you heard, an ounce of prevention is worth a pound of cure, and we believe in that. so it gives us no benefit to

deny preventive services. we follow u.s. task force for preventive services guidelines, doing routine health assessments, providing chronic illness clinics with all of the necessary medications that go with that, and on a frequency, and fortunately we have a locked up population so the fact that they miss an appointment, that doesn't happen very much. they get to come when they're supposed to come. we have a very active utilization management depth that that there's and discharge planning. pharmacy benefits manager, a form larry, we have a copay which is legislatively mandated and it's five dollars for these prescriptions that are considered to be nonchronic care. so it's prescriptions that the inmates come in and say, i want. i want this, i want that.

well, it's a $5 copay. and then thirdly, under pharmacy, we have been fortunate because of our relationship with the medical college of georgia, to be able to have access to 3040b pricing for purchases, primarily for h.i.v. drugs. we actively manage our network, both with hospitals, physicians, ancillary services, durable medical equipment, prosthesis, physical therapy, occupational therapy and rehab, active medical relief process so any inmate who has a guesstimate life expectancy of less than 12 months from a terminal or chronic disease can be considered by our board of pardons and paroles, the clemency entity within georgia to be considered for early rev lease. we have telemedicine and

telepsych, which allows us to extend provision of medical services not necessarily on site but threw the telecommunications. a modular surgical unit in a prison for ambulatory services we can take the inmate to the print, and we have a forensic unit that that 22 bets and the whole purpose of most of those is so that we have found the more services we can provide behind thejdofofofyfn wire, ratn sending the inmates out into the community, it is both cost effective, cost efficient, and our first goal is to provide public safety. that is the primary purpose for that. so, we do a good job, i think in providing and getting very creative and providing more and more services behind the wire. our challenges are, again, what i say is the grain -- graying of

inmate population. all states are experiencing inmates agings because they have longer sentences, longer confinements, and all of the illnesses that you experience in the free world, with getting old, our population experiences. so all the mobility issues, the cancer and all, we experience that. they have physical incapacity and immobility, progressive degenerative diseases. we have an increased concentration of chronic illness, and this is in the face of diminishing budgets for health care, and with that diminishing budget we have to get very creative because there's increased liability associated with that funding decrease. we find that we have to establish protocols of who will get treated for certain diseases because of the treatments being so incredibly expensive. we have an increased mental health burden with dim mensa, depression, psychosis, destructive behavior and the cost of psychotropic medication

and their baby 'ers to re-entry, which is transition of medical care to appropriate providers. you can imagine a lot of providers in the community are not necessarily opening their doors and welcoming someone who is just being released from prison to come in and provide care. often times they come with no benefits and no resources to help pay for their services. vocational certification and employment opportunities is also a barrier. in georgia we have a law that says those who become certified, like a certified measure assistant, cna, that can provide services in a nursing home, that certification doesn't hold up once they're release it. they're not able to use that. and thirdly, the residents restrictions including those for sexual abuse and those that are confined under -- from a sexual sentencing, they have 1,000-foot yard rule with churches,

schools, parks, et cetera. so the recommendations that i would have based on all of these is that 340b pricing be made available and more easily available to the department of corrections throughout the united states. we would establish guidelines for the potential impact on the departments of corrections regarding the affordable care act, so we're not just kind of figuring it out as we go. thirdly, that we would promote electronic health record exchange, meaning that electronic health records would be able to be exchanged through all venues, from the prison system, through the jails, on out into the community providers. and lastly to expand federal funding participation for inmate eligible to help offset the costs within our prison system. thank you. >> okay. thanks, dr. lewis. let's turn to dr. turney.

>> good afternoon, everybody. my name is asher turney, a medical doctor from rural alabama and tennessee, and i've been a doc for ten years, and after hearing some of the discussion earlier from miss bey and miss rowe, i just wanted to say, we all can have a family member that could be incarcerated, and i want them to get the best care they deserve. in my experience, i have not had that same issue. as a medical director for tennessee, i work with the department of corrections, and we try to avoid some of those circumstances that they described. so, i don't think it's overwhelming across the board pervasive issue but there are certain situations that i worked

every day to prevent. so i just want to say, my discussion today will be a little bit wider in scope, and mainly on some of the issues that we deal with in corrections. but as i said, completely empathize with anyone who has had circumstance like that because that's what i went into medicine to prevent. i'm a preventative medicine urgent medical care specialist. our goal is to help the underserved. this group is the underserve, the same vulnerable population that often times are at healthcare centers, the same population that needs access, and so it's the same job for me whether i'm behind the walls or not. so, just want teed kind of describe our situation in tennessee. i am a vendor partner to the department of corrections. i work with centurion, a company

with 60 years experience in managed care, also in correctional health care. our parent company, mhm service provide us a lot of opportunities and tools to fulfill the individual state needs. we provide cradle to the grave service on -- as well as behind the bars with centurion. we provide local solutions to some of the most difficult situations our partners face. we also use evidence-based medicine, which i probably something that ises a newer term but evidence-based solutions, leveraging technology, predictive modeling, innovative preventive health models to limit severity of disease. some issues to note. so, tennessee -- welcome to tennessee, everyone. we are a department of

corrections, 21,000 inmates across the state. roughly 11 facilities. small subunits but roughly 11 facilities, and we do have some challenges. each state has its own unique challenges and obstacles related to correctionalhawk heck, and we have -- correctional health care and we have worked hard to improve those issues and make them more manageable. the population as a whole, just in general -- the general population has diseases that affect it. right? and those same issues mirror in the correctional population. often times, sometimes it's magnified. like we talked about, hepatitis~c, infectious disease, or mental health illness. a significantly higher rate of mental health illness within corrections than you do outside the walls. we have tried to deliver solution0s the tdoc to improve

those concerns. centurion has managed the tennessee contract since 2013 and sufficiently decreased the number of admissions to the hospital and e.r. by treating on site, by getting in earlier with preventive health to decrease the need for los hospitalizatio, and trying to get to patients before an e.r. run and tried to install electronic -- telehealth, and telehealth -- just to kind of quickly refresh -- is a mechanism by which you can use the internet connection and video or telephone to essentially discuss with a professional on one side and an inmate patient on the other with a nurse, have a facilitative medical visit, and i allows you to get the patient

much sooner. in the past you have to transfer outside the walls. so we have brought that onboard, and it also decreases the -- reduces the risk of public safety of transferring and saves money from the standpoint of transportation and security. we have also developed some new on-site services which are continuing to improve the overall health and well-being, and i would talk a little bit more about that on the next slide. i do want to say this to kind of tag long on dr. lewis' comment, managed care philosophies are improving halve outcomes, at least in tennessee. so, i wanted to just kind of briefly discuss a few considerations to some of the illnesses. this is not an exhaustive list of conditions, but as we talked

about earlier, mental health disease is a lot more pervasive in the correctional population and we have to bring innovative, multidisciplinary approaches so mental health, medical, legal, corrections, everyone at the table, to ensure that these patients get the care they need, and our patients often times -- especially in the female population -- they have a history of being a victim to violence, and substance abuse, and those do make more complicated treatment pathways. as far as unique populations within creeks, i think we all have elder pop lates. we take care -- populations but you take care of them but the difference in correction is the elderly population is

physiologically older than theronologyal age. so the life expectancy of a patient that has been incarcerated dish -- i see them as patients -- late 50s, whereas the general population is much nor near 70 or 75. so, it's a huge difference and so these patients are showing up to our door, much sicker than they would have been, and much further along in the process of diabetic, diabetes, neuropathy, whatever the worst case scenario. so it's a lot more difficult issue than probably has been previously discussed. but as far as older populations, we try to look at aggressive chronic disease programs. we're developing on, site long-term facilities. long-term care facilities to provide assistance to, let's say, demented patient and hoss

hospice care. canner increases as we age and a lot more patients with cancer and we're trying to treat thoses humanly, respectfully, on site. as far as our female population, females have a higher -- as a group, a higher incidence of mental health disease versus male counterparts. less than one percent of enmites in tennessee are identify mail but they have a significant number of medical problems and it's a completely different environment to treat patients. we do try to bring innovation to their care by providing -- let's say with pregnant patients, we provide centering, centering ises a new concept, being evidence-bears it. it shows essentially that you work with a group of patients instead of one patient, and their experiences can then be changed and they learn from the

grouping. son stead of one-to-one doctor-patient ratio, you have large group where you can have a nice exchange and actually facilitates better customer services, and we care about our inmates and improves better outcomes, we have less preterm babies, and larger birth weights. so it's a good thing. lastly, hepatitis~c. that's the elephant in the room. enheight tis c is a very concerning illness. okay? it is surpassed -- it has surpassed h.i.v. as the largest cause of death or highest cause of death for viral illness as of 2007. our populations -- nationally, 17% or so, 17-point something percent of the inmates we have incarcerated have help tight --

hepatitis~c. in tennessee it's ten time the general population rate so 10% roughly. there's no vaccine available. not like hepatitis b. and unlike h.i.v., it's potentially curable. the new medications available are -- may lead to that but they're very, very costly, and difficult to get... ry, very costly and difficult to get. so we are working toward aggressive management of our hepatitis c cases as this is a public health issue. we don't talk about it often, but a large percentage of inmates will be released and we want it make sure they have the least issues so that they can have a most successful life and contribute back to society. my goal is not to be the yuj and

jury. my goal is to provide health care for them. so, you know, talking a little bit more about innovative programs in -- in corrections and as we talked about earlier, it decreases the need for transfer, including costs of staffing for officers and it reduces the time of diagnosis and it reduces the public safety risk. we also go further to -- pardon me we also go further to go beyond just the treatment model. we look for prevention. we as an organization are are moving toward a more customer-driven model and i think empowering, you know, if you look at, like, 20 years ago when managed care first came around for 20-plus years now, actually, but when they first came around we were more focused on providers, networks

facilities and now we're actually focused on patients, consumers and we do that through wellness programs. we do that through education and this is a correction. we have a program called nurture. it can be group or individualized, but it's a telephonic disease program that provides wellness to the inhama. for example, a nurse can speak to an expert. this goes beyond having a practitioner on site, but having an expert. say diabetes. y'all have a diabetic expert talk to you and counsel you on mechanisms to improve your health and it's been shown outside the walls to be very successful and we're in our terminal negotiations to implement it across our state. so these are goals that we're trying to implement to improve

the ultimate health and well-being of the patients. as far as the future, the future is re-entry in some cases and in those cases we want to make sure we provide a bridge, and electronic health record as one of the guests asked earlier would be a great bridge because it provides the information and efficient means to get to on safety in a hospital or to a community health care center or to on some other group upon that can provide health care after the patient has been -- um -- um -- discharged or the sentence hasec piered. at this moment corrections as a whole does not have that opportunity. there are a number of difficulties of getting in the system and i think that that would be a potential opportunity for policymakers to look at finding a way to improve it it

because this is ultimately like we talked about, public health and it can cut to the u.s. public health system in some way where that information, before they come in can then connect to while they're in to when they get out and it be a complete pathway or complete life cycle and that will ultimately help the patients in the long term and that's one of our goals. like i said, centurion is a company, and i am completely in support of taking care of people when they need care and we try to find individual solutions to our state's concerns. i want to just focus everyone on the recommendations. my recommendations for policymakers at this point will be to look at integrated methods to provide behavioral or medical care on sites before and after entry and re-entry. consider electronic health

records as a mechanism through, maybe through high tech or through some of the other funds that are still available and find a mechanism to assist department of corrections in developing an electronic health record so we have an ease of communication and it helps decrease unnecessary reoccurring medical business because you have the information from the previous medical visit and oftentimes they will reord onner what the previous doctor has because they recognize it hasn't been done and they don't have the information immediately available and they have to make a decision then because they have it on their shoulders. lastly, to continue to develop the discipline of correctional health care by empowering department of corrections and other medicalstitutions to partner and have medical residency programs and medical students and allied health professionals and provide some type of funding to assist the department of corrections in

hiring qualified professionals similar to the national health service corp where you have difficulty with accessing health care, they arc lou mon allow mo and that's how they recruit more nurse practitioners, et cetera. thank you. >> thanks very much, dr. turney. we have about 20 minutes now where we can get some our panel and give you a chance to ask some questions as we go forward. you can hold up a green card, go to a microphone or tweet, and i'd like to get us started if the folks at the microphones would fore bear just a moment. >> yeah. >> if i can get all of our panelists to really talk about

something that was raised earlier in the program and asher, you were talking directly about delivering the kind of quality, evidence-based care that is the standard as we go forward and dr. lewis, as well. what kind of standard have you talked about the need for regulation and oversight of the proprietary providers of health care in prisons or the proprietary prisons providing health care. what kind of a mechanism for oversight and what kind of standards are in place that you either have to impose or live up to in the case of dr. turny and steve, maybe you can talk about the broader picture to go beyond the specific states that are represented here. >> i think part of it just shows

the alliance's gift to represent. and dr. lewis because of her personal background in managed care and because of dr. turny and because of the commit am to use managed care principles within a correctional institution has demonstrated the managed care principles and i think in both instances it's a question of self-regulation that's occurred both in georgia and tennessee that shows the progress that dr. you lookis and dr. turney has created. the larger question i'm hearing you ask is should there be some other regulatory type framework that would regulate correctional health, and i'm not prepared to answer that question one way or the other, other than to say as we both heard dr. turney say that because of their commit ams to managed care principles that they've been crossing that bridge over to the island of corrections by using managed care, electronic records and

telehealth as mechanisms to cross that bridge. as to whether there should be other mechanisms i'll leave that up to those of you who get to stay here in congress to figure that out. >> dr. lewis, what do you do with those private prisons? what standards do you hold them to? >> they're held to the same standards with our s.o.p.s, as all my facilities within the state. we perform annual audits to make sure that they are delivering the health care by the standards that we have outlined within our standard operating procedures within the department. >> we, too, the standard of care is no different inside or outside the walls. so we are held to that same level of care. we'd have to defend it in court otherwise. what i will say is that we internally also do audits in addition to our state agency partner. they do audits on a regular basis, but we do audits

internally to ensure quality measures and we are american correctional associations certified and some of the other contracts are national health care certified and those also have rigorous standards similar to the quality commissions. is it part of your contract negotiations, as well? i was thinking in terms of your negotiations with tennessee in the case of dr. turney. >> you know, i'm not -- i'm not as familiar with that portion. i can get that answer, but i'm not familiar with that portion. >> steve, in addition to what we might do further, do you have observations about what the other 49 jurisdictions might look like? we have the picture that d.c. wasn't there at the top. >> not at the time that they were incarcerated for sure.

this is part of the state, federal and local partnership that up until now we've aloud each jurisdiction to govern the island of correctional and correctional health as they see fit and at times to having someone like dr. lewis who has something that she brings forth. i think there is no national framework, if that's your question, ed, where we have made a societal decision that we're going to make sure that correctional health follows managed care principles. we have not because of the inmate exception, the typical medicaid protections that are available to consumers have not been available within a correctional health setting because they have not been subject to any of the cms standards or quality review or anything else that's required. so, frankly, when you've seen one jurisdiction, you've seen one jurisdiction. >> and i do want to quickly. >> we do have -- i was thinking more of contractual and we do

have measures in place that our vendor partner would look at frequently and there are incentives to make sure they're running smoothly as far as contractual. >> very good. thank you. >> yes, go right ahead. >> thank you for having us today. specifically, dr. lewis. lots of strategies, i'm curious about once you're outside of the wire, i totally agree, trying to do the best you can inside makes a lot of sense and that structure, never missing an appointment, that's real. once you're outside, unless you have a really strong community intervention and we're able to coordinate that care from inside to outside that wire. how do we encourage those strategies? what do we do other than create a link with the medical record and things like that to ensure that those folks suddenly thrown out in this community once

again, freedom and all of this time where they were more successful in a structured environment and made those appointments, how do we encourage and make sure that once they're out they're a part of something. thank you some. >> i think a couple of things. one is that we can do a better job at trying to educate the inmates about their illnesses during our chronic care visits so that they have an appreciation for the severity of the illness. secondly is identifying public health providers that are going to be willing to accept those discharged inmates into -- under their care. we're having some difficulty with that, but it's hard to say, but the more catastrophic an illness is for an inmate, we have discharge planners who try to coordinate the care upon discharge. for someone who simply has hypertension or diabetes that's well managed and unfortunately,

we're not doing as good a job of trying to hook the links up on the outside, but those patients that have cancer and chronic diseases, major chronic diseases, we try really, really hard to coordinate the care with the a poim ppointments at leaste beginning. we give them 30 days of medication to get them started. we try at least six months ahead of time to identify and research what benefits that are available for them with medicare, medicaid veterans and try to get the paperwork started so the resources are in place until they get discharged. >> we're seeing a difference between expansion and non-expansion state and these folks are being able to come out with insurance and the non-expansion states both dr. lewis and dr. turney can speak to the challenges they're having and having providers that are

essentially a no-pay patient. >> you want to identify yourself, please? ? i'm a longtime, life time public health official and in an expansion state and it seems to me that a real lever is consumer education and also with the state contracting because in an expansion state, the state is paying for corrections and the the state is paying for medicaid and so in order to coordinate those benefits, on the hospital side we're looking at accountable care organizations so hospitals are coming out and working with community providers to make the discharge meaningful to avert unnecessary readmigs and we're not doing that and maybe someone on the panel is aware of those innovations with following that individual in a contractual arrangement so there's risk sharing or savings sharing by the corrections officer as well as by the public health rf. i ask anyone on the panel.

>> there is an example of that in argon and part of their ccos. they actually have set up a separate post-incarceration cco contractually which has a risk-sharing arrangement with that. that's the only one that i can think of off the top of my head that the state has done that. i think that's a great model and that's a great example we want to do. the question is that given the federal system and federal, state and local autonomy is how do you stimulate and encourage those types of programs? is that a federal grant program or an initiative program? but yes, it's an excellent point. >> great panel. thank you. >> we have a question right there. >> oh, yes, here we go. >> my name is ricka and i'm with the national association of community health centers or nac and my question is to mr. rosenberg, but anyone who has input. so as a staff member at nac, we

have thousands of member health centers nation wide including those in partnerships. in addition to your island metaphor, i want to point out that the correctional system is also hidden behind concrete walls, layers of varying policies that the local state and federal level that are gray, at best. the the inmates are disappeared behind the walls and they're labeled criminal and the incentives for keeping it that way. so from your experience of success building these partnerships at the community lev level, i'm wondering if you have any words of wisdom and lessons learned that you can share while we're at this national level and have the local member health centers that could potentially want to reach out and create these partnerships and may not know where to start or who to contact. >> i want to identify a huge obstacle which i think you know

about which has been unwilling to allow health centers to have a scope within service to find care behind bars. while you have the health centers that are the number one appropriate provider to be going out and providing care behind bars, it has not been able to allow that change for scope of service. for those of you who are here on the hill i want to point out that that's not an insignificant issue. in terms of lessons learned going forward, i think the number one thing is about understanding, having a community board, community health centers are 51% user boards and having that community board, understand and identify that the folks behind bars are members of the community who are temporarily displaced and that's an educational process within the community health care movement and if you look at ashe, who started this model. he started it by him identifying

that the folks in his county jail were community members displaced and he reached out to the local community health certains to provide care. that came from the correctional side. i think the challenge is from the health center side, having an absolutely educational understanding that these are the fathers, brothers, uncles of the women and children we primarily serve and that they are a part of our community and as such we want to reach out into, behind those barbed wires and steel walls and guard towers to figure out how we create integrated care and the samhsa version is another good model for that to be disseminated out to health centers. >> yes, ma'am? >> hi. so my name is amy testimony as and i work for the community of affiliated plans and we represent 58 non-profit managed cares throughout the country and we have one in particular in rhode island that is working with their health services

department as well as the prisons to help with that handoff between, you know, the prisons and them coming outside and i particularly was curious if you have any research about the return on investment. we're looking at this on on rhode island, but any research that's been done about how the handoff it you willy saves state medicaid programs money. >> and the answer is no because of data sources. so the washington state data i was able to describe to you is unique because they merge their jail booking data and their medicaid data and their mental health utilization data and it allows them to tie that data. no other state has that data at this point in order to be able to do that research. and the correctional leader, and

and they link, and we have a master patient index or some way of tieing that data together and we don't have a way to do that and there are a lot of hipaa concerns and other concerns to do that and they weraible to do that again because of the unique data set that allow them to easily identify folks. >> okay. we have just a few minutes left. i'm going to ask you as we go through these last couple of questions to pull out the blue evaluation form if you haven't done it already and fill it out as you listen so that we can get some feedback on -- what we ought to do to serve your needs better. >> just a very quick question. yes. both of you talked about hospice care and long-term care inside the prisons and i was just wondering why can't these people be released at that point? why are they still incarcerated when they probably are not a threat to society anymore?

just wondering. >> for georgia, our clemency entity which is what we call the board of pardons and parole has the authority and we have an active medical reprieve process. right now we probably have 65% of those inmates that we submit for consideration that are being granted a reprieve. so those inmates who have, as i said, a guesstimate life expectancy of less than 12 months or a chronic termial or otherwise disease that will be particularly costly to the state we can submit those for consideration. we have a similar process in tennessee, but our providers would be responsible for providing those cases to the department of corrections and they would go through the normal process. the process has been reese leent revised to include some long-term issues that are not,

per se, terminal, but are debilitating to be humane. >> this is the last question and maybe the toughest. what do you anticipate the new hepc drug having on correctional health care expenditures? >> the easy answer is bankruptcy. and therefore, what? dr. turney was talking also about trying to deal with very large incidents of hep-c population. are you going to prioritize? are you going to test everybody? are you going to allow the use

of civaldi for some subset of those folks and how are you making that decision? >> you want to take it? >> we're going to and have started to prioritize those inmates and basically leave the decision to the g.i. specialist who is rendering the care as to who is most appropriate given the financial constraints. civaldi is a very effective drug, but to treat an inmate with fewer side effects which is the big plus for that roughly $120,000 so with that type of price tag you can imagine we can't treat everybody for $120,000, otherwise we wouldn't be able to treat the heart disease, diabetes and everything else. we do have to prioritize and we do have to follow protocol and we have to look at the federal bureau of prisons guidelines for treatment of hepatitis c.

>> asher, you want to weigh in on that one? >> it's not an easy answer. we have a long way to go with the discussion and there has not been any defined schedules that have been released on a national scope. the aasld and the fbop have released preliminary guidelines which we also use. we have an advisory committee that has an infectious disease doc or hep atoll gist based upon their medical needs. case in point, hepatitis c and hiv, they don't work well together and they have both illnesses your disease goes much faster and so they're put at the top of the list. we look for worsening clinical courses and we put them to the top of the list or, you know, prioritizing. so there needs to be still a lot

of discussion between local, federal, pharma corrections and public health on this discussion and we really need to find a solution and it's got to be a collaborative deal. >> okay. well, if you could put that composite slide back up, i would appreciate it. just for your use, our crack staff led by marilyn sa rshg afini on this one has put together a summary of the evaluations that several of our speakers today have put into their presentations. so when you're looking for things that you can work on, we've put it all on one-page for you. so take that as grist for your legislative mill or policy mill. i want to thank you for your attention to a really to the

under-appreciated set of issues that we were able to address and for that, by the way, i want to thank our friends at centene for allowing us to put this program together and helping us recruits some of the folks you've heard. i want to thank our panel and particularly, i want to recall the eloquent testimony that we heard from deborah roe and jacqueline craig bay as well as the panelists you see up here and ask you to join me in thanking all of them for a very useful discussion on a very difficult topic. [ applause ] >> and thank you ed.

is. >> for the first to conversations justice

did the introduction now serving as the director of the embassy at the state department with the format of tonight's program is a no-holds-barred debate on the highly controversial subject. i thought i should say a word why i think the subject is so important. when our constitution was written our founders were concerned of keeping the federal government's role to keep it resembling the monarchy they fought against and the courts were to check the power of both the injuries were to check the power of all three. but today congress and the executive branch hardly resemble anything our founders could have imagined. congress has been incapable to pass any legislation or

confirm presidential appointments and spends most of its time raising money to investigate the investigate -- executive branch and is doing a good job by less than 10 percent of americans but those departments and agencies that run the country on a day-to-day basis and congress created very clearly interested these policies yet members are now claiming the president is exceeding his constitutional authority by trying to do things around the edges with mayors equality contagion filling vacancies the government positions that make our country run. the question before us is whether the constitutional claims with use of executive power are exaggerated in if we should be concerned about whoever sits in the white

house running ruptured -- ref shot in the warehouse. with a highly respected supreme court justice calling for six constitutional amendments with gun-control and redistricting it is no longer heresy to suggest our constitution may need a revision to separate the powers of issue your honor to have on the left harvard law professor mr. ogletree who taught president obama everything he knows about constitutional law. [laughter] on the right we have one of the nation's foremost supreme court advocates who argued in part to the recent split decision that obama exceeded his authority to make recess appointments to the nlrb.

mr. estrada. our moderator is the referee of a bigger debate in new york staff writer from the four most journalist and television commentators covering legal matters matters, jeffrey toobin. let the debate begin, a gentleman. [applause] >> eight you. thank you. hello everyone. speaker boehner says the house of representatives will sue the president of united states for exceeding his authority. can the house to sue the president? >> it depends on the claim.

back up. [laughter] it is a very difficult lawsuits to frame with the legal documents of the competency of the core. to fight those political branches. mostly the house will overcome a number of pieces that congressman is senators do not have standings in court. they're trying to do get around that with the boat of the house this is not the usual case somebody who lost out in the process is angry but really the institution but that raises a number of issues under case law if they can claim the legal injury that the law recognizes. usually people come to court to claim you to eliminate or

child or house that is what is the injury in fact, is that is what is needed. but the suit that is contemplated is you failing to comply with the affordable care act or also known as obamacare and not immediately obvious how the members of the current house of representatives of their injured in that will show their members of the public who are injured a and could sue. sova my view is it is a very challenging case for the house even if they do have a vote and if i have to bet on the court's upholding that standing i would not give them more than 50/50.

>> what do you think? >> repeat the question. [laughter] i will be shorter. might answer is to sue the president over and over again and there will not be successful they're attempting to make the apportioned case the obama is not afraid and he said what? doing my job and he is. that will be the debate between him and congress. but the reality is the president has already been stung by the recent decision how executive power is limited but they left him a little window for him to do what he needs to do and the president has supported this idea because he has been

stopped by everything he wants to do. the senator from kentucky said he would be a one-term president but he was wrong. but the knicks to an f years will be interesting using his power not just to disagree with the house but to use that will be important. >> you think he will have standing but will just lose on the merits? >> i think the president will still have the executive power i think people say let's get something done. it is a do nothing congress people are responding that

somebody needs to do something how do not support anything for the past six years? >> there is always a very attractive claim to say the aside is not letting me going back through 1789 those who wrote the constitution said the giver and that is -- the government that is best is the government that governs least. because what is happening here is there is a do nothing congress everybody says that when congress does not go their way but we have

that fundamental questions of policy that is reflected in the white house. unless they come to an agreement and they both keep insisting to have 99.44 nothing will get done. you cannot have change unless you come to an agreement is intended to have the ability to slow things down. >> talks about a specific as that planned the lawsuit is discussed, it has not been filed yet but the court claims the affordable care act says the employer mandate should take him on a certain day in this

administration delayed that day. we all know how the republicans feel about obamacare and their claim is the food is terrible and the portions are too small. [laughter] do they have a point that the law says there is a day to the president changes unilaterally. how can he do that? >> of the flip side i think it is very difficult to put under those claims if the court would consider them on the marriage. but then to come into effect the president says i will not do that.

so things of that nature but to with ago the supreme court slap down the epa that you shall regulate if the polluter issues more than 100 times. you can say that is unreasonable but the court says you cannot do that. you don't have a choice congress says of these terms. but the point if this is terrible food is and we want more of it, people should be entitled to experience from their representatives and if

people don't like them this is why. we can say we will change them but you cannot simply say you have a rush to fix it on the fly but disregarding what the statute says? >> we have had debates in congress as long as we have had congress on both sides of the aisle. as much as we think it is troubling but it is no different like the bill of rights cover protection from women. what this president is trying to do is move the ball for word. it would make a big difference some of the things he has proposed is good for america. i think because of his policy. no question. he will continue to put the pedal to the middle to major

the next to a half years things will make a big difference if they will overrule the affordable care act is not new every time we come up i remember when president clinton was running they call that the hillary care act. >> what ever happened to her? [laughter] >> she was -- is running for president and elected the first president of united states. >> but that would not make any sense. [laughter] >> no question people are enthusiastic and supportive but my friend is also a

great democrat she will not run against clinton in 2016 but some day she will be president like candidates is a great in smart person i had the honor to teach, and michelle obama she will be a great president if she ever decides. >> but what about the business you have to do this on such a date and he delays the of what? is that okay? >> yes because he has the power to do what he needs to be done he is been doing a lot of things trying to make the affordable care actlaqz i:obamacare ears plural

because it will help the american people that is good reason that i think the reality is people who are pore or rich and have problems with the president but the reality he tries to do stuff internationally, but globally, hopefully that will not happen to win for work. >> talk about a recess appointments. i am sorry go-ahead. >> i don't mind he rallies for the president. [laughter] i am more choosy then that. but the fact is if a private person was employed by the private employer excuse by the president for providing the mandate.

that person clearly kansu you to come into court there is a tangible benefit i want to know. they have stinting and merits. as the president has executive power and one of those is that it has to be done on a certain term in he signs that act he has to comply with that. >> but isn't there a doctorate of law that says the prerecord said two years ago the affordable care act was constitutional as attacks from the commerce clause cyrus has the ability of a constitutional

authority or statutory authority to delay the imposition of taxes with their discretion isn't that the delay justin exercise of that? >> to answer is. no. with the first. the power of tax has a representative but there is a statute that gives ways to the edge treasury department but what the statute now the question is if this is dead date of congress or actually the enforcement the and i would think one of those are

true. >> talk about recess appointments. this is their eruptive appointment in we can all agree inerrant in the horse and buggy era congress was out of session cover they could not come back. they regard many months that the time. >> we do things including fill vacancies so congress gave him power.

he did the informal survey how people like the affordable care active and everybody was against it. but obamacare was no way. but the president today for a job to explain what is affordable care act. >> but we have been trying to get this for a very long time it is costly and it is necessary 71. >> susus a sewage. so that strait of people

saying we cannot do it spirit talk about recess appointments. we're a law school classmates but this was one of the great arguments i have never heard in the supreme court. almost as great as his socks. so what was the issue? >> the constitution has for these purposes coming tools how you go about naming federal officers. the general rule is what you do all the time that you cannot appoint somebody to be an officer unless you get

the advice isn't the consent of the census of the five nominated been filibustered but if the senate is the degree don't have the appointment. the next one says when you can appoint temporarily. it is unusual to say that is part of the constitution when the reason is they will not confirm the nominee because of the general rule they are entitled to do that you don't have the appointee. so this may be viewed as obstruction by some but it

is what the constitution says to get the senate to agree. the president got frustrated because he cannot keep the nlrb staffers and it is true that the appointees were not timely confirmed but that was not the case with the recess appointment that was one nanosecond after he nominated them. but at the time the senate was cut the senator who was spee rick but they said do

effectively. is he said some were also challenging who have been to

be the legislative here to assess a that was not is a resource with the supreme course said iran was has the

keys if they choose to stay by coming in every 30 -- three days with the seventh segment session that is good enough but then the senate gets to decide if it is in recess. if they think they are not

then the president does not have that power. this is a question that may vary depending if the president's party is in control of the senate if not he will never have a recess. bet you hear that parts of the constitution the most have never heard of moscow it cannot be away floor were in there and could give the senate wants to have dave recess then i can vote and

step the damaging to right side of the bridal to change the constitution every day and month. we cannot do that. >> that the filibuster is not in the constitution. >> but it is practiced over and over. >> cut to the chase. it is not constitutional.

>> and necessary. >> i don't know about that. >> but it makes clear the senate can discuss and debate and agree and disagree who should be appointed. oh whole series but the constitutional authority has rules how to run the business. there is the case the 19th century supreme court that one to rule if we have not enough people from the team bird for those surgeons that are into a nose count to 51 on the ground. the supreme court said they can do that. it is a quorum continued -- with the casexdhd$mhheñ of