>> attention, please. i don't want to interrupt your lunch munching, but i'd like to get us started, if we could. we have a lot of ground to cover and some great people to hear from. i know i'm looking forward to that. myom name's ed howard. i'm with the alliance for health reform, and i want to welcome you to this program on behalf of senator rock feller, senator blunt, our board of directors. the program concerns the health of people in prisons and other correctional facilities and the health care they need and the healthe care they receive which may be the same and may not be the same. if you're concerned about getting care to those who need it, you need to care about health.budg states spend about $8 billion on

correctional health care in 2011 which was about $1 in 6 of their entire correctional budget. and that level of spending shouldn't be surprising. this is not a healthy population. that includes a loent of folks with chronic conditions, with mental illness, with addiction disorders, and it's getting older as the population ages. ad so it's not surprising that states are trying a whole range of different strategies to get r handle on correctional health a spending, everything from contracting with third partiesag to deliver the care to having more services delivered on site to taking advantage of new health coverage opportunities for inmates. so today we'reto going to take a look at how well those cov strategies and some others are working and what kinds of policy

changes might be helpful to improve both the quality and the value of the care that this population receives. and as we examine these issues, we're pleased to have as a partner in today's program the centine corporation which contracts to provide medicaid coverage in a dozen states, operates a number of services, and hater in the program you're -- later in the program you're going to hear from dr. asher tierney who's from aaf joint venture that provides a correctional health care in which centine is a partner. let me do a little housekeeping before we get started.pa if you want to tweet, that's how you do it, with the hashtag prison health.ou w if you need wi-fi in order to tweet or to do anything else, the credentials are on theif screen. feel free to make use of them.

there's a bunch of good material in the packets that you received when you came in, including biographical information about all of the folks on our speaker, and there's a one-page materials list that actually lists everything that you have copies of and additional material that you can go to for further edification. materials list and additional material you can go to for further edification. all of that is on our website, allhealth.org. particularly that one pager you should try online because you can click on those things and you don't have to worry about copying a long url. there's going to be a video recording available of this briefing in a couple of days on our website followed by a transcript a day or two after

that. and you can follow along with the slides that the speakers will be using today on that website. if you're watching on c-span, you can find all these materials and the slides on our website. you can follow along if that is what you would like to do. word about questions at the appropriate time, you can ask a question three ways. there's a green card you can fill out and hold up. there are microphones at either side of the room you can use to ask in your own voice. and you can tweet us a question using the hash tag, and we'll monitor and get that up to the dais. the only other thing i would ask is as we go forward, that you fill out the blue evaluation form that's in your packet so we can improve these programs as we

go along and cover subjects and have speakers that would be of the most interest to you. to let's get to the program. our format is a little different than usual. there are going to be two panels, not just one. you'll have a chance to ask questions after each one. first we're going to get an overview of the issue and then turn to a view of these issues from some people who understand them from first-hand experience. and then a second panel will address concerns about health care and the correctional system from the standpoint of some folks who are charged with delivering that care. so starting with our first panel. i'll introduce them all to keep the continuity of the conversation going. we're going to start with steve rosenberg, who's the president and founder of community oriented correctional health

services. is there a pronounceable acronym? >> cochs. >> those of you who watch the redskins tryout understand coaches are important. steve's been working to assure health care access to vulnerable populations for more than 40 years and provides technical assistance to correctional systems toward that end. debra rowe is the executive director of returning citizens united here in d.c. with 20-plus years experience supporting and advocating for those re-entering from incarceration. she holds a master's degree in human services and spent several years incarcerated herself some years ago. finally, we'll hear from jacqueline craig-bey, who's a supervisor at a domestic violence safe house here in town and an advocate for inmates and former inmates among other vulnerable groups.

he's the first paralegal hired by the university of d.c. law school, and before she, quote, turned her life around, unquote, as she phrases it, she spent more than 20 years in prison herself. so we're really looking forward to hearing from you folks, and we'll turn first to steve rosenberg. >> well, thanks, ed. thank you, all. welcome for joining us. i'm really appreciative to have the opportunity to talk about this relationship between public health and public safety because they're so closely tied. as ed mentioned, i'm president of cochs. our goal is to break down the barriers and build connectivity between our public health and public safety systems. before proceeding, i just want to make a quick distinction between jails and prisons to make sure everybody understands what we're talking about. jails are county or city-based places where folks are held prior to trial or for being sentenced to a misdemeanor usually less than one year. prisons are operated by state or

federal governments, and folks go there for a longer sentence. with the data you have in front of you, shows the point in time snapshot of who's in jail and who's in prison, but i'd like to turn your attention to the data below that, which is that more than 11 million folks annually circulate through our nation's jails. those folks are there for a very brief time, and 4% of them, only 4% of them end up in state prison. 96% are released directly from jail back into the community. so when we look who's cycling in and out of jails, what we see are these are our nation's most marginalized folks. they're largely young, largely nonwhite, largely poor, and suffering from diseases way in pro proportion to it the rest of the population. let me just give you some data you can see that. these are the rates of hepatitis for justice-involved individuals compared to nonjustice-involved

individuals. and you can see as we get older down the age spectrum, the gap widens largely. this is the data on hiv compared to justice-involved individuals compared to nonjustice-involved individuals. this is the data on substance use disorder. there was a recent study that was completed. it's known as the adam study, which looked at the incidence of substance abuse disorders. so we obviously can see that much of our criminal justice system is inherently a public health challenge. folks have substance use disorder. it's that disorder that's having them end up in the correctional system. similarly, folks with serious mental illness -- look at that

data. national population compared to local population. and for women in particular, this is a much greater challenge. more than 30% of women who have incarceration or justice-involved have a serious mental illness. obviously what we're depicting to you is this is a challenging population. but what i want to show you are their insurance status. prior to january 1st, 2014, 90% of individuals leaving jail were uninsured. so we make this investment in stabilizing their health care because we are required to under the supreme court's ruling which said that public jurisdictions have a responsibility under the eighth amendment to not be deliberately indifferent to the citizens that are under their charge. so we make this investment in stabilizing them and then the minute they leave the street, typically we lose that investment. but it's the bottom point i think should be of more concern to all of us.

a study showed that of individuals incarcerated who had a chronic disease, 80% of them did not receive treatment for that chronic disease in the year prior to their arrest. so if you have an untreated behavioral health disorder, you're not receiving treatment for that disorder in the community. the likelihood of your ending up exposed to the criminal justice system becomes fairly high. so what do we know about what happens when we treat the underlying substance use disorder? washington state in 2003 ran a natural science experiment. their data system allows them to organize the jail booking data, medicaid claims data, and mental health utilization data. the state provided $30 million of general funds to its five largest counties for them to go ahead and treat as they saw fit individuals with substance use disorder. and the results were startling. notice this is not completion of

substance abuse treatment. this is exposure to substance abuse treatment. the first thing you want to notice is the arrest rate went down by 33%. simply by exposing folks to treatment, the arrest rate went down by a third. for every dollar that the state spent on treating folks with substance use disorder, it saved a hard $1.16 in criminal justice costs. if the cost of victims of crime are included, the savings was $2.87 for every dollar saved. that's on the justice side. now let's look on the health care side. as you've seen, folks with justice experience have very high morbidity. prior to 2003, their health care costs were increasing at a rate of 5.5% annually. once they were exposed to substance abuse disorder treatment, all of the sudden their costs dropped to 2.2% annually. here in d.c., folks are always talking about bending the cost

curve. what you have in front of you is a perfect example of a cost curve that was bent simply by providing access to substance abuse disorder treatment. >> bent out of shape. >> that's right. bent way out of shape. where that leaves us are recommendations for you as policymakers in going forward. i really want to give you four things to consider. one is, these are folks who are not mothers with kids with ear aches who are going to bang on the door of the welfare system say, give me a medicaid card. a study in 2009 in massachusetts showed while there are only 3% of individuals in the state uninsured, 22% of individuals showing up at publicly funded substance abuse treatment programs whose demographic parallel is exactly that of justice-involved individuals, largely male, largely poor, those folks had an uninsurance rate of 22%. so the very first thing i want to make sure you all understand

is that targeted outreach for enrollment will be necessary. this is going to be a complex and difficult population to enroll. and that the use of the medicaid administrative claiming program by public safety entities can facilitate their enrollment. most folks within the public safety world know nothing about the medicaid administrative claiming program, and that is a great opportunity for use for states and localities to bring in resources to enable them to enroll this challenging population, and as you just saw, enrolling this population will save everyone funds. the second is that we need to understand the relationship between substance use disorders and the criminal justice system and how health care providers both in the corrections and in the community can work together to increase public safety. that's the second take home. the third take home is wanting to talk a little bit about how it's important that we

understand that we have an our books going back to the medicaid program this thing called the imd exclusion, or that is people who are patients in an institution of mental disease cannot receive medicaid. the purpose of that goes back to the desire when medicaid was started to not have the state hospitals suddenly become financed by the federal government. well, our science and vocabulary have advanced since then. we now understand things like th thraumatic brain injury. i want to urge you to give very careful consideration as policymakers to make sure that statutory folks that are 50 years old that may not be relevant in today's world, that we don't fail to meet this juncture of public health and public safety because we're trapped in old statutory and regulatory language and we figure out how to change that

world in order to really facilitate the opportunities. and i guess my last recommendation would be to make sure that we pay attention to how we build bridges. we have these two separate silos. we have a criminal justice silo over here. we have a community health silo over there. these silos have not been very good at talking with one another, at informing one another. i guess the third would be that here in d.c. on a policy level, that we do 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 incarceration at the

reformatory in the late 1980s, i witnessed the disheartening maltreatment of who were ill and resided in my dorm. for example, the women who were sick were kept at the very end of the dorm. this was during the time when hiv and a.i.d.s. became prevalent in communities can and several of the women that i am referencing had hiv 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 and forced 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 hiv disease. while studying for my job, i read a report from the centers

for disease control that stated that 16% of those entering d.c. jail had hiv infection. and i wondered, how did they know that? i began my personal inquiry because i knew that hiv testing was not being offered at that time. i'm going to venture out and say that they were blind testing these inmates, and after advocating for testing in the jail, the correctional medical staff was frantic that they didn't have the resources for the testing, which confirmed my suspicion about the blind test. i see the same parallel with hepatitis c and that many, many women, some of whom have served ten years or less, who have had blood draws have contracted hep c infections and were unaware of their status until they came home and visited a free community physician's office and learned of their results from a laboratory result there. one inmate who has served 15

years in prison went from lewisberg to cumberland, then to petersburg and then to petersburg camp 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 center for disease control, the prevalence of hep c infection in prison inmates is substantially higher than that of the u.s. general population. among prison inmates, 16% to 41% have ever been infected with hep c and 12% to 35% are chronically infected compared to 1.5% in uninstitutionalized u.s. population. it's primarily associated with a history of injection drug use. cdc recommends that correctional facilities ask inmates questions

about their risk factors for hc infection during their entry medical evaluations. inmates reporting risk factors should be tested, and those who test positive should receive further medical evaluation to determine if they have chronic infection and/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 that they are incarcerated. they have the right to know. all of this is happening in the private prisons. in closing, the inmates have reported that their health services are limited, and they're being charged. they have to pay $5 to sign up for a sick call and 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 a few days

ago that 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 the system. this concludes my story, and i'm happy to answer any questions. and i do concur with all of steve rosen burg's 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 $1,000 a pill has a cure. prison systems and other correctional facilities right now are having to figure out how to deal with the kinds of percentages and the numbers of inmates and residents that debra

was talking about. so public health meets -- >> public safety. >> correctional policy. you bet. now we'll turn to jacqueline craig-bey. thank you so much for being here. >> thank you for having me. excuse me. my name is jacqueline craig-bey. i am a former inmate. i have several stories from when i was incarcerated as it relates to the medical in prison. while i was there, i broke my 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. i mean, 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. when i finally got to the hospital a week later, the doctors over there laughed about it and called one another and come and see this funny thing that was on my foot. the medical facility just didn'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. 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, you know, women here know that you have to have a six-week checkup after having a child. well, i saw the doctor in the hallway. he just touched my stomach and said, oh, you're fine, and that was my six-week 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 hiv, and they're afraid for other people to know that they have hiv, 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 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 to the line, everybody knows what everybody's taking. so some people don't want to take their medication. and that's 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 pass -- die 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. before they would take them to a facility to be treated, they would 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 and sitting them 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.

when they got there, nobody said that 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 would call attorneys and people that i knew in the district and have them fly to connecticut to help one of the sisters or brothers that needed some help, because otherwise we'll sit there and languish in prison with no help at all. and it's just a really sad thing

for us to languish away like that. and that's 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've 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 in -- 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? you know, it's just point-blank like that. they're still dying. all of what i 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 ill -- our women -- d.c. gave up the rights to our inmates. we were blessed to be in lauton reformatory during that time. but they closed our local prison. so all of our women are in a medical facility way down in florida. d.c. residents. that's another thing. they're far away from home, and they're sick and they're far away from home. at least if they were in their

vicinity -- and they're supposed to be in a 500-mile radius, but they're not. they're all over the country. our inmates are spread all over the country. but it's not just speaking for our d.c. inmates. any inmates. i collaboraslacollaborate with 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. just like i said, if you're blind testing people and they don't know, just like cancer, if it's undiagnosed, then -- i mean, look at the people that go to the doctor and they tell you, you have six months to live. but that cancer was in your body longer than that. these these are -- it's like they're just forgotten buzz they're locked up. you know, when they come home,

they have what they call the new federal second chance act. because they deserve a second chance. so these long-imposed sentences and then you're not going to take care of them. like i said, you have -- in oklahoma, you have a lot of elderly geriatric people. a man came home 70-something years old. he called my colleague and said -- he's still on parole. they said i got 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 was 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. but still, why hold somebody to 77, 85 and they're sick. 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 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 need some type of release. but you're in a cell in agony. in the a cell, not in an infirmary. at least in an infirmary, you can lay down and you can -- and you're getting seen or anything. a year to see a dentist, a year -- and you're paying for it now. you're paying for it. you work, and if your family's 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. it's -- no, there's no progress. there is no progress. >> ed? >> steve, please. >> i don't disagree with anything you're saying, but i want to frame it. traditionally, we send folks out to islands when they need to be incarcerated. devil's island, alcatraz, australia. parts of the united states early on in our history. we've 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 you and jackie describe are not uncommon. the blessing is we're all in this room in this very lovely senate chambers today. we're in this room for this

lovely senate chambers today 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 record 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 offenders. but the important thing, i think, 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 intertwined. and managing public safety by keeping folks on an island is not the way that we want to go 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 you can either fill out a card or go to a microphone so everybody else can hear your question. 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. >> so -- >> i would 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 that we can. >> i'm dr. caroline poplin. i'm a primary care physician. we ha i have a quick comment about disability. i worked for social security disability for a while in baltimore. very often we could not get prison health records. i mean, we had people who

weren't in prison who had no records at all. the people who were in prison, we knew they had records, but very often the prisons wouldn't send them and the states wouldn't work terribly hard. that should be something easy, especially with electronic records. >> debra? >> i want to say, we have in the district made progress in that area. i used to facilitate a federal partner's meeting. it was 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 an inmate leaves the prison, they had trouble getting their record. so now all of the records follow them. they all go to unity.

they're centrally located in unity. that's one progress we have made in the district. >> and a 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 -- >> wow. >> -- for medicare paying for any services provided behind bars. thst also a statutory provision that 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 as 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 islands. obviously, medical records is a 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 and the query becomes how do we build a bridge. >> thank you. >> if i can just -- i don't know whether this is something that you've 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 as a quarter that would give you credit toward medicare credit eventually. >> and the answer is no. >> no? okay. >> hi. >> yes, sir? >> glen field, urban affairs advocate. debra, i heard you mention a 500-mile law. we constantly let this government get away with it.

we have a law that's established that any d.c. court offender or d.c. inmate couldn't be moved no more than 500 miles just to keep them with your family members, your loved ones. people in the district of columbia get locked up and have been traumatized. we have racial disparity going on here. any inmate -- like 3,500 return back into the city. 85% goes back within three years. so you celebrate. am i right, ms. rowe? you celebrate you made it past three years because it's a revolving door. i'm just asking steve and the panel, if you can agree with me, in the prison industrial industry, that they make a profit of this revolving door. when you don't get proper health

care, as far as mental health care, when you have been traumatized, post-traumatic stress disorder, you're coming back to prison. and the private 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 the private industry and your pill cost $1,000 or 30 pills cost $600, you're not going to get that medication. you're not going to get 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 are concerned is medical. a lot of people have been suffering, and they're going to suffer more. then they're allowed to come back out on the street. i'll point it out to steve, you know, mostly that we do need -- wouldn't you think we need some advocacy and some monitoring

mainly at these private prisons and making sure that their discharge plan starts earlier than eight months. doesn't mean 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 can and things of that nature. because people take drugs because they've been traumatized in these prisons. so it creates a criminal. because they've been traumati traumatized. they 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 they haven't been treated correctly. so you got worse off than what you were before you went in any system. i'd like the panel to chime in on any and all of that. thank you. >> i'd like to answer that question by framing slightly differently. we have proprietary companies

that provide medicaid services through the united states. but those companies are regulated. those companies have performance measures they need to meet contractually. the challenge with the correctional health system is by and large an unregulated industry. and if you have an unregulated industry, 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. i think, again, that's partly where being in this room in this building points to something we don't allow in any other sector of 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 statutorily required? so we now 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 an underlying challenge that

our federal system has allowed state localities to make their own determinations as to what regulatory or quality assurance framework they're going to 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 want -- my name is mary tierny. i'm a pediatrician. i had the privilege of getting a grant. we did outreach to youngsters 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 in kansas who ran the program and the medicaid director who was full force behind this in dr. andy ellison, who at the time was the kansas medicaid director. he was magnificent in getting this. the 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. >> thanks, mary. >> can i go ahead? >> yes, linda. go right ahead. >> linda flowers, aarp public policy institute. so in my mind -- and thank you for this panel. it's just been tremendous and very insightful. i'm learning a lot. so it sounds like there's this cause 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 you could -- 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 increakreecreased spending at t level once most of these people get out of prison. i think that could be a powerful tool for states to use to try to leverage better improvements while people are incarcerated in federal penitentiaries. and the other thing is i wonder if you can also try to 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 a lot more money on other unanticipated costs because you've made a way for people to have a pathway to health care.

but -- and also, i wonder if you can talk about any best .. states working together to have a better outcome while people are incarcerated and then when they transition out into a state -- into states. so i think you can beef this issue up a whole lot more than what i'm hearing. >> linda, those efforts are actually already under way. the federal bureau of prisons has just instigated a requirement for a standardized release in terms of doing substance use disorder evaluation. i think we're starting to see that kind of process come down. on the medicaid expansion side, i think the data that i gave you from washington state speaks very loudly to how there's a direct relationship between health care 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 intertwined and interconnected, and it does

not serve anyone's interest let alone the taxpayer to keep folks isolated on an island without the appropriate regulatory framework that we come to expect as part of our federal state and local partnership. so what i would say is the data 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 we haven't made this conceptual leap. that's what we're all here today to talk about. we haven't made this conceptual leap that says we need to figure out how to build conceptual leap that has to das m >> bob, last question. bob with the incident of social medicine and community health. i remember when senator woolford ran, senator from pennsylvania, and made a big case about prisoners being one of the only populations in the united states at our right to health care. in fact, that was based on a supreme court decision. how does that president --

president not create the political power to implement the kinds of solutions that you're hinting at? and have a we learn anything from the tuskegee experiment? it 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. >> there are several questions. first i have to be a nerd here and slightly correct, it's native americans under treaty and incarcerated individuals, the two individuals in america for whom health care is a right and not a privilege. in terms of a gamble on the supreme court case, what the supreme court ruled was that the responsibility of a jurisdiction is to not be deliberately indifferent to the health care needs of an individual. so, for example, if you had a

lawyer going back to your example, debra, waiting a year for a dental point, that dental point was made. i wasn't deliberately different to that person's needs, and they go back to the regulatory framework. that if you again think about how we diminish care within the committee setting we require a certain number of days after which an appointment has to be made. we require a certain number of credentialing in order to provide care within the context. we don't do that in correctional health. we are still on an island i think that's the point you will hear me say over and over again this afternoon. >> all right. i don't want to cut people off but if you 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 in, maybe we'll find some stray questions at the end of q&a for the second panel. thank you so much. >> thank you.

[applause] >> i would ask our second panelists to come up if i could. [inaudible conversations] >> all right. we are reconstituted, panel was. you've heard from steve rosenberg. the other panelists on my right, dr. sharon lewis is the medical director for the georgia department of corrections. she's a board-certified pediatrician and a nationally respected expert on quality assurance with more than 20 years of experience in health

care and managed care. and right now she is responsible for delivering adequate and cost efficient care to the inmates in the georgia correctional system. next to her is doctor asher turney who is the medical director for century in of tennessee which is a joint venture. with which tennessee contracts to provide health care services for its correctional system. dr. turney is board-certified in both urgent care and occupation medicine and has a 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. as you all heard i am a board-certified pediatrician, so i to 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 fractional departments throughout the united states. fortunately, we have had lots of success in improving the health care that is being delivered to the inmates in our custody, and fully respect the gamble ruling with mandated health care. to start out, george as little bit of difference here. with the ninth largest state in overall population but we are the fifth largest prison published. we have roughly 55,000 offenders in prison at about 145,000 probationers.

94% of our population is male, and 6% is enough to think that this is a get reflection of other states. the male population, unfortunately, is predominant african-american. 62% of our population is aged 25 after 4 45 chronologically and those big more in a second 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 our prisons but we also operate county and privatization, transitional day care detention centers and boot camps. again were responsible for constitutional, providing constitutional mandate healthy. does everyone understand what that is? it means that a basic three

minimal standards. what it's all inmates at the right to access care. secondly, they have the right to care that is ordered. and thirdly, they have a right to professional opinion of those providers to order that care, such that the example that i give is that we can't have a dentist that tries to do an appendectomy. so that's the third piece of it. our demographics are such a the 37% of the inmate population has significant chronic illness. that number in percent us up after about four years. four years ago is about 33%, and i think that every state is challenged with this where they haven't increased acute and chronic disease and the disease is most prevalent are hiv, cardiac, hepatitis c come into illness and cancer. 17% of the georgia population receives mental-health services,

and there some difference with that. in the female population 50% of our female population is receiving mental health services compared to about 12% in the male population. we think that's attributed to cultural differences and then the mostly in the female it is behavior disorders, the mood disorders. we have most of our inmates say unlike age, their physiologic age exceeds their chronological age because of their lifestyle prior to incarceration. they experienced drug use, lifestyle factors of smoking, alcohol, nutrition deficiencies, and lack of activity or meaningful activity. minimal to no health care from either medical, dental or mental-health and have accelerated listing of chronic diseases. we have an increased population of age, blind and disabled, and our older, our admission age is

older. the average now is about 33 years of age, and then it therefore translates into her old age of the population which is about 36 years. so we're not getting more young people in that i call, but rather, you know, the older folks are starting to come in. in fiscal year 2013 these are some pretty startling statistics for us. those that are over 35 years of age represent 54% of our population and account for 75% of the claims. those that are over 50 years of age are 18% of the publishing and account for 47% of the claims. the most importantly is that those that are over 65 represent 2% of our population but account for 8% of the claims. so if you're looking at $180 million budget, that's a lot of money. those that are over 65 years of

age, their average claim cost is around $3500, versus those that are less than 65 years of age representing only 591. so that's a dramatic difference just based on the age. i'd 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 that we have to provide. we are continuously having an intake of chronic illness which includes those women that come into our population pregnant and we are responsible for all other prenatal care and delivery. and again he would be high risk. so all of the services that we are required to provide, we're having to get very creative in the strategies that we use in order to provide the necessary

mandated health care. that covered a population that you see listed below represents a population that's covered in our general population. we have probably about 6000 inmates who are housed in what we call private prisons. there are several prisons within our state that take it so the cost of that does not come out of our per diem. so again here's our creativity. as you heard i had a long history with managed care organizations, and whether you like them or don't or whatever, it's the world we live in. they are successful. so some of the principles of those managed care organizations have used, we have applied in the department of corrections. the first one being and a very proud of this is what we call the summer of health care benefits. it is the same document or a similar document that you receive when you sign up for your own insurance. it basically tells you what is

and is not covered and is or is not eligible and visit with the insurance cup it will and will not pay for. but for us it lists out what services are eligible to the inmates and which was part. it puts everybody on the same playing field because the inmates then understand what services will 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 medical hernias, for audis. we don't pay for cosmetic surgery but we don't pay to treat your acne order male pattern baldness. we don't pay for your sex change operation or your sexual activities. so those are the kinds of services that are not considered eligible. all of the medically necessary services, those are the keywords, medically necessary services, are provided to the

inmates within our custody. this document has been reviewed by the office of our attorney general, and again it provides the framework for constitutional health care. the second foundation is preventive care. i know you've heard an ounce of prevention is worth a pound of cure, and we truly believe in that. so it does us no benefit to deny preventive services. we follow u.s. task force for preventive services guidelines doing routine health assessments, providing chronic illnesses clinics with all of the necessary medications that go with that. and on a frequency. and fortunately, we have a lockup population so the fact that they miss an appointment, that doesn't happen very much. they get to come when they're supposed to. we have a very active utilization management department that does preauthorization and concurrent review and discharge planning. our pharmacy benefits

management, we have an active pharmacy and therapeutics committee. we have a formulary, we have a co-pay which is legislative mandated it is $5 for those prescriptions that are considered to be non-chronic 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 co-pay. and then thirdly we're under pharmacy is we've been fortunate because of our relationship with the medical college of georgia, now known as georgia regions, to be able to have access to 340 d. pricing for some of our purchases primarily right now for hiv drugs. we actively manage our network, both hospitals, physicians and services, prosthesis, physical therapy, occupational therapy and rehab. with an active medical reprieve our compassionate relief processed so that any inmates 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 parole school which is the clemency entity within georgia, to be considered for early release. we have telemedicine and tele- site which has allowed us to extend provisions of medical services not necessarily on site but through the telecommunications. we have a modular surgical unit in one of the prisons where the and let researchers were able to take the inmates to that prisonn to be one of the surgeries done. and last we have a forensic unit in one of the tertiary care hospitals that has 22 bits. the whole purpose of most of those is so that we have found the more services we can provide behind the wire rather than send the inmates out into the temerity, it is both cost-effective, cost efficient, and our first goal is to provide public safety. that is the primary purpose with

that. so we did a good job i think and provide a getting very creative and providing more and more services behind the wire. our challenges are, again, what i was is the grain of the inmate population. all states are experiencing inmates aging because they have longer sentences, longer confinements, and all of the illnesses that you experience and that the free world experiences with getting old, our population experiences to all of the mobility issues, the cancer and all, we experience that. they have physical incapacity and immobility, progressive degenerative diseases. ribbon increased concentration of chronic illness, and this is in the face of diminishing budgets are health care, and with that diminishing budget we have to get very creative because there's increase 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 dementia, depression, psychosis, social behavior. the cost of the psychotropic medications and we experience barriers to reentry which includes transition of medical care to appropriate providers. you can imagine that a lot of providers out in the committee are not necessary opening their doors and welcoming someone who has just been released from prison to come in and provide care. oftentimes 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 basically says that those who become, quote, certified like a certified nurse assistants, cna, the combined services in a nursing home, that certification doesn't hold up once they are

released. they're not able to use that. and thirdly the residence restrictions including those for sexual abuse and those that are confined under, from a sexual sentencing. they have 8000-foot yard rule with churches, schools, parks, et cetera. so the recommendations that i would have based on all of these is that 340-b pricing would be made available and much more easily available to the departments of corrections throughout the united states. we would establish guidelines for the potential impact on the departments of corrections regarding the affordable care ask 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 for all venues, through the prisons has, through the jail on out into the community are vital to analyze

to expand federal funding participation for inmate eligible the to help offset some of the cost with an emphasis. thank you. >> okay. thanks, doctor louis. let's turn to dr. turney. >> good afternoon, everybody. my name is asher turney. i'm a medical doctor from rural alabama and tennessee. i've been a doctor for about 10 years, and hav after hearing sof the discussion earlier from tonight and mr. zubrow, i just want to say that we all can have a family member that could be incarcerated. i just 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 would try to avoid some of the

circumstances that they describe it so i don't think it's an overwhelming, across the board, pervasive issue. but there are certain situations that the, you know, i work every day to prevent. so i just want to say, my discussion today will be a little bit wider in scope and it will be mainly on some of the issues that we deal with in corrections. but as i said i completely empathize with anyone who's had circumstance like that because that's what i went into medicine to prevent. like i said i'm a preventive medicine urgent care specials. our goal was to help the underserved. this group is the underserved. it's the same vulnerable population that often times a service that fail health care centers and need access. so it's the same job for me when i'm behind the walls or not.

so i just wanted to try and describe our situation in tennessee. i am a vendor partner to the department of corrections. i work with centurion which is a company that has about 60 years experience in managed care, also in correctional health care. our parent company provides a lot of opportunities and tools that we can fulfill the individual states needs. we provided critical day-to-day service on the same team side as those behind bars with centurion. we provide local solutions to some of the most difficult situations our partners on face. but we also use evidence-based medicine which is probably something, it's a newer term always evidence-based solutions

launching technology, predictive modeling, to limit the incidents and the severity of the disease. that's just some issues to note. so tennessee, welcome to tennessee, everyone. we are a department of correction, 21,000 inmates across the state. roughly 11 facilities at the small subunit but roughly 11 facilities. we do have some challenges each state has its own unique challenges and obstacles that are late to health care and we've worked really hard to improve some of those issues and make them more manageable. the population as hell, just in general, the general population, those same issues mirror in the correctional population. oftentimes come sometimes it's magnified, like we talk about

hepatitis c as an infectious disease, or mental health illness. you have a significantly higher rate of mental health illness within corrections than you do outside the walls. we have tried to deliver solutions to the tdo see that improve those concerns. we have officially decrease the number of admissions to the hospital and er i treated on site. i getting in earlier with our preventive health model to decrease the need for hospitalizations and trying to set of programs or get to patient it would have and exacerbation that requires and er run. we've also tried to install what was done actual across the state. we've installed electronic -- s.o.r.t., telehealth, excuse me. telehealth, just to kind of really to be refreshed is a mechanism by which you can use

an internet connection and a video or telephone to essential discuss with a professional on one side and an inmate patient on the other with a nurse. have a facility to medical visit. it allows you to get to the patient much sooner so that because in the passion to transfer outside the wall. we brought that on board and it also decreases, reduces the risk to the public safety of transferring, and it saves money from the standpoint of transportation and security. we've also developed some new on site services which are continuing to improve the overall health and well being. about chocolate more about that on the next slide. i do want to say this is just a cut tag along with doctor loses. managed-care philosophies are improving health outcomes, at least in tennessee.

so i want to just the kind of briefly discuss a few considerations to some of the illnesses. and by far this is not an exhaustive list of conditions, but as we talked about earlier, mental health disease or illness, excuse me, is a lot more pervasive in the correctional population. so we have to bring in innovative multidisciplinary approaches. so mental health, medical, legal, corrections, everyone at the table to ensure that these patients get the care that they need. and our patients oftentimes, especially in the female population, they have issue of being a victim to violence and substance abuse, and those to make more complicated treatment pathways.

as far as unique populations within corrections, i think we all have elderly populations. we take care of them whether you're inside the walls or not. but the difference in corrections is that the elderly population in corrections is physiologically older than their chronological age. so you have a person that, the life expectancy of a patient, a patient that's been incarcerat incarcerated, i see them as patients, late '50s. whereas the general population is much more or 70 or 75. so it's a huge difference and so these patients are showing up to our door much sicker than it would have been, and much further along in the process of diabetes, neuropathy, whatever the worst-case scenario they coming. it's a lot more difficult issue than what has been previously really discussed. but as far as older populations,

we tried to look at aggressive chronic disease programs. we're developing on site long-term facilities, long-term care facilities to provide assistance to a demented patient by patient that needs continual nursing care. we also are providing hospice care. of course, we understand cancer increases in incidents as we age. so we are having a lot more patients with cancer. we're trying to treat those humanely, respectful the on site. as far as our -- i'm sorry. as far as our female population, females have a higher, as a group they have a higher incidence of mental health and disease versus their male counterparts. with less than 1% of inmates in cincy ar our female but they doa significant number of medical problems. it is a different, completely different environment to treat patients. we do try to bring innovation also to their care by providing

let's say with pregnant patients, we provide centering. centering is a new concept. it's been evidence-based. it shows essentially you work with a group of patients instead of one patient and their experiences and in the exchange and to learn from the gripping. so instead of the one to one doctor-patient ratio, you have a one to five or a little bit larger group we can have a nice exchange. it actually facilitates better customer service so we do care about our inmates and their considerations about our health care but it also improves better outcomes. so we have less preterm babies enlarger birthweight. so it's a good thing. lastly, hepatitis c. that's the elephant in the room. hepatitis c is a very concerning illness, okay? it has surpassed hiv as the largest cause of death or

highest cause of death for viral illness as of 2007. our population nationally, 17% or so, 17-point something percent of the inmates that we have incarcerated have hepatitis c. almost one in five. in tennessee it's about 10 times the general populations rate. so we have about 10%, roughly. there's no vaccine available. it's not like hepatitis b, and unlike hiv, hepatitis is essentially durable. the new medications that are available may lead to that, but they are very, very, very costly and difficult to get. so we are working towards aggressive management of our hepatitis c cases, as this is a public health issue, okay? we don't talk about it often but a large percentage of inmates are going to be released, and we want to make sure that 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 judge and jury. my goal is to provide health care for them. talking a little bit more about innovative programs in corrections, as we talked about earlier, you know, telehealth you can use it probably. it decreases the need for transfer, including cost of staffing for officers. it reduces the time of diagnosis and reduces the public safety risk. we also go further to do -- pardon me. we also go further to go beyond just the treatment model. we look for prevention. we as an orientation are moving to more customer driven model. i think empowering, if you look

at, like 20 years ago, when managed-care first came around, 20 plus years actually, but when they first came around we were more focused on providers, networks, facilities. now would actually focused on patients, consumers. and we do that through wellness programs. we do that through education. this is occurring in corrections as we speak. with a program called nurture. it's a telephonic -- he can be group or individualized but it's a telephonic disease management program that provides wellness to the inmates. so, for example, a patient can actually, with a nurse as the facility, speak with an expert. this goes above and judges having a doctor on site or a nurse practitioner on site but haven't expert in whatever the telescope let's say it's diabetes. you 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. we are 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 reentry in some cases, and in some cases want to make sure we provide a bridge. electronic health record as one of the guests asked earlier would be a great bridge because it provides the information in an inefficient means to get to a safety net hospital or to the committee health care center, or to some of the group that can provide health care after the patient has been discharged, or the sentence has expired. at this current moment corrections as a whole does not have that opportunity. there are a number of

difficulties in getting into system and i think that would be potential opportunity for policymakers to look at funny the way to improve it. so this is like what we talked about, public health. if we can connect to the public health system in some way where that information, the for the coming, can then connect a while there in so when they get out and it would be a complete path with or complete lifecycle. that will help the patient in the long-term, and that's one of our goals. like i said, centurion is a company, i am completely, 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 recommendation. my recommendations for policymakers at this point would be to look at integrated methods

to provide behavioral and medical care on sites before and after injury and reentry. considered health electronic melchor -- maybe to high-tech or through some of the other funds that are still available, find a mechanism to assist department of corrections in developing electronic health record so that we have communication but it does decrease unnecessary reoccurring medical this is because you have the information on the previous medical visited often times doctors will w reorr what the previous doctor had because it recognize it's already been done. or they don't have that information of able and have to make a decision then because the liabilities on the shoulders. but i think it's very supportive. lastly to continue to develop the discipline of correctional health care by empowering department of corrections and other medical institutions to

partner and have medical residency programs, medical students and other allied health professionals, and provide some type of funding to assist the department of corrections in hiring qualified professional, similar to the national health service corp. where you have difficulty with accessing health care. well, they allow money available to pay back loans and that so they can recruit more physicians, news -- nurse practitioners, et cetera. thank you. >> thank you very much, dr. turney. we have about 20 minutes now where we can get some interchange among our panelists, and give you a chance to ask some questions as we go forward. remember, you can hold up a green card. you can go to a microphone or you can tweak. and i'd like to get us started

if the folks at the microphones would forbear just a moment. if i could get action all of our panelists to really talk about something that was raised earlier in the program, and asher, you're talking directly about delivering the kind of quality evidence-based care that is the standard as we go forward. dr. lewis as well, what kind of standards kashmir we talked about the need for regulation, for oversight of the proprietary providers of health care in prisons, or the proprietary persistence -- prisons provide health care. what kind of a mechanism for oversight and what kind of standards are in placethat you have to oppose or live up to in the case of dr. turney, and

steve, maybe you could talk about the broader picture that goes beyond the specific states that were representative. >> ed, i think part of it just shows the alliance's gift in choosing the states the ribs and. dr. lewis because of her personal background, and dr. turney because of centurion commitment using managed to principals within a correctional institution have demonstrated to us what happens and the effectiveness of bringing managed-care principle to i think the question is in both instances, it's a question of self revelation that occur both in georgia and tennessee shows the kind of progress that both dr. lewis and dr. turney have created to the larger question i'm hearing you ask is sure to be some sort of other regulatory type framework that would regulate correctional health within a different context, and i'm not prepared to answer the question one way or the other, other than to say i think what we both heard dr. lewis and dr. turney cities because of the

personal organizational commitment to managed-care principle that they've been crossing that bridge over to the island of corrections by using managed care, electronic records, telehealth as mechanisms to cross that bridge. there should be of the mechanism, i lived up to those hdepicted to stay here in congress to figure out. >> how about the specifics? dr. lewis, what do you do with those private prisons? what standards do you hold them to? >> they are held to the same standards with our sops, as all of 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, honey, instead of just a different inside or outside the walls. we are held to the same level of care. we would have to defend it in court otherwise.

what i will say is that we internally also to audits in addition to our state agency partner. they do audits on a radio basis but we also to audits internally to ensure quality measures. we are under congressional association certified, and some of our other contracts our national commission on correctional health care certified, those also have rigorous standards similar to some of the quality commission. >> is a part of the contract negotiations as well? >> actually i was thinking in terms of your negotiations with tennessee in the case of dr. turney. >> you know what, i'm not as fully with a portion. i can get that answer but i'm not the money 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've got the picture that maybe d.c. was right up there at the top. >> not at the time that they were incarcerated for sure. so again i think this is part of our state, federal local partnership that up until now, we the loud each jurisdiction to govern the island of corrections and crucial help that they see fit at times are blessed with having someone like dr. lewis it was a personal commitment to she brings forth virginia organizational commitments again from centurion and mhm that they bring forth but i think there is no national framework. that's a question where we have made a disciple tasha a societal decision we make sure direction health falls managed-care pencils but we're not because of the in the exception. the typical medicaid protections that are visible 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 and our expense when you've seen one jurisdiction,

you've seen one jurisdiction. >> okay. spent i do want to quickly -- we do have cost 50 more about contractual, we do have measures in place that our vendor partner would look at regular the and charges, some call it liquidated damage. there are answers to make sure things are running very smoothly, just as far as contractual. >> very good, thank you. yes, go right ahead. >> thank you for having us today. specifically, dr. lewis, lots of strategies but i'm curious about, once you're outside of the water i totally agree, trying to do the best you can inside makes a lot of sense, that structure, never missing an appointment, that's a real. once you're outside, much of a really strong community intervention and able to coordinate that care from inside outside that wire, how do we encourage those strategies? what do we do other than create

a better link with electronic medical records and things like that to ensure that those folks were then suddenly thrown out in this committee once again, freedom and all this time where they were more successful in a structured environment, they made those appointment. how to encourage and make sure that once they are out they are a part of something? thank you. >> a couple of things. one is we can do 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 under the care. we are having some difficulty with that, but it's hard to say, but the more catastrophic and ellis is for an inmate, we have discharge planners who try to

coordinate the care up on discharge. for some who've sent as hypertension or diabetes is well managed, for joy we're probably not doing a good job of trying to put 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 appointments at least in the beginning. we give them 30 days of medication to get him started. we try probably starting six months ahead of time to identify and research what benefits that are unavailable for them with medicare, medicaid, veterans, et cetera, and try to get the paperwork started so that those resources are in place by the time they actually get discharged. discharged. >> i would say we are seeing a major difference between expansion and non-expansion states on this. expansion state it's much easier to build a great that linkage

out in the community. because these folks are able to come out with insurance. the non-expansion states of the both of dr. lewis and dr. turney can speak to some of the challenges they are having and having community providers willing to see this will be a no pay patient. >> i am a long time, lifetime public health official, and in an expansion state, it seems to me that a real lever is consumer education but also with the state contracted because in an expansion state of the state is thing for correction the state has been for medicaid. in order to coordinate those benefits on the hospital side were looking at accountable care organizations so hospital coming out and working with committee providers to make the transition after discharge meaningful to avert unnecessary readmission. we are not doing that and it is one of them is aware of those kinds of innovations with phone the individual outside of the facility into the community in a

contractual arrangement so that there's risk-sharing or there's saving sharon by the corrections officer as well as by the public health officer. i asked anyone on the panel is as examples of that sort of innovation spent there is an example of that. in oregon in part of their cco they 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 the. i think that's a great model and i think that's a good example we want to do. i think the question is, that given our federal system, federal, state and local autonomy, the question is how do you stimulate and how do you encourage those kinds of programs? is that a federal grant program? is that initiative? i think it's an excellent point.

>> i am with the national association of committee health centers, and my question is mainly to mr. rosengren, anyone who has input. so as a staff member at nac we have thousands of member health centers nationwide, 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 at the local, state and federal level that -- the inmates mr. kind the walls and the label criminal and the financial systemic incentives for keeping it that way. so from your experience of success building these partnerships at the committee level, i'm wondering if you have any words of wisdom and lessons learned that you could share for us at nac while we're at the national level but then have these local member health centers that could potentially

want to reach out at great these partnerships but minot even know where to start or who to contact. >> the first thing i want to do is want to identify a huge obstacle, which her sets up until now been unwilling to allow health centers to a change in the scope of service, care behind bars but one have a health centers that may be actually the number one provider to be going out and providing care behind bars, hrsa up until now so going to allow that change or scope of service. so for those of you who are here on the hill, i want to point out 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 come hell senator a 51% user boards, and having that committee board understand and identify that the folks behind bars are members of the community who are temporarily displace. i think that is a huge educational process within the

committee health center movement. i think that if you look at the work of sheriff ashe who started this model, he started it by him identifying the folks in his county jail were committee members temporally displaced. he reached out his local gym and health centers and invited them into his facility to provide care. that came from the correctional site. i think the challenge is from health center site, having an absolutely educational understanding that these are the fathers, brothers, uncles of the women and children primarily serve, and that they are part of our community and as such we want to reach out into behind the barbed wires and steel walls and guard towers to figure out how we create integrated care. samhsa hrsa initiated care is a good model. >> i work for the association of committee athlete plans, and we

represent 58 nonprofit managed care organizations threat the country and we have one in particular in rhode island who is working with their department, their health services department as well with the prisons to help with that hand off between, you know, the prisons and then coming outside. and i particularly was curious if you have any research about the return on investment. were looking at this in rhode island, by any research that's been done about how the handoff actually saves medicaid, state medicaid programs money? >> and the answer is no, because of data sources. to the washington state data i was able to describe to you is unique because they merge their jail booking data, o their medicaid and other mental health utilization data. they have an index that allows them to tie that data. no other state has that data at this point inwards to be able to do that research. i think in rhode island you've been very blessed, you have wall

as the correctional leader who is understood and has been worked with trying to figure that out but i think we have something similar happening in the state of vermont right now was also an effort to try to figure how to link those systems. but, unfortunately, without insurance call the master patient index or somewhere time that data together, we don't have a way to do that and there's a lot of diplomatic concerns another concern for being able to do that. are able to do in the washington again because of the unique data set that allow them to easily be identified. >> we have just a few minutes left. i'm going to ask you as we go through these last couple of questions to poll 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. i think both of you talked about hospice care and long-term care

inside prisons. i was just wondering why can't these people be released at that point? why others don't incarcerated when they probably are not a threat to society anymore? just wondering. >> for georgia, i can speak is that our clemency entity which is what we call the board of pardons and parole, has the authority to decide whether someone is eligible to be released. we have a very active medical reprieve process. right now would probably have about 65% of the inmates at we submit for consideration that are being granted a reprieve. so those inmates who have as i said i'd estimate life expectancy of less than 12 months, or a chronic debilitating terminal or otherwise disease that's going to be particularly costly to the state, we can submit those for consideration. >> and we have a similar process in tennessee but that is actually, our providers would be responsible for providing those

cases to the department of corrections and they would go through the normal process. the process of been recently revised to include some long-term issues that are not per se terminal, but our debilitating, to be humane. >> okay. maybe this is the last question. it's maybe the toughest. we have sort of talk around it for a good part of the conversation. what do you anticipate involving in the new hep c drug having on correctional health care expenditures? >> easy answer is bankruptcy. >> and, therefore, what? dr. turney was talking also about trying to deal with a very large incidence of hep c

population or are you going to prioritize? are you going to test everybody? are you going to allow the use of so-called he for some subset of those folks? how are you going to make that decision? >> we are going and have start to privatize those inmates. basically leave the decision to the g.i. specialist who is rendering the care and who was most appropriate, given the financial constraints. sovaldi is a very effective drug, but to treat an inmate with fewer side effects which is a big plus for that, we're talking about roughly $120,000. so with that type of price tag, you can imagine we can treat everybody for one of $20,000, otherwise we wouldn't be able to treat the heart disease and

diabetes and everything else. so yes, we do have to prioritize. we got to follow protocol, and we are currently looking at the federal bureau of prisons guidelines for treatment of hepatitis c. >> asher, do you want to weigh in on that one? >> it's not an easy answer. i think that we still have a long way to go with the discussion. there's not been any definite defined prioritization schedules that are been released on a national scope. the aa s.o.b. and the fbop corporation some preliminary guidelines which we also use. we have an advisory committee that has an infectious disease doc for herpetologist to assist those based upon their medical needs. case in point, hepatitis c and hiv, they don't work well together. so when you both illnesses, your disease goes much faster. so they are put at the top of the list. we look for worsening clinical

courses, and we put him to the top of the list. or you know, prioritizing. there needs to be still a lot of discussion going local, federal, pharma, corrections and public health on this discussion but we really need to find a solution but 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 on this briefing have 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 your policy mill. i want to thank you for your attention to a really underappreciated 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 recruit some of the folks you have heard. i want to thank our panel, and particularly i want to recall the eloquent testimony that we heard from debra rowe and jacqueline craig-bey, as well as the panelists you see a pair, 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. [inaudible conversations] >> today that metropolitan junior baseball league of richmond, virginia, hold a symposium in which coaches, journalist and former major leaguers talk about the relationship between african-americans and baseball and what baseball can do to encourage players from the african-american community. we will have that live at 1 p.m. eastern on c-span2. >> tonight on "the communicators," three members of congress talk about their technology legislation. >> i believe in an open internet, a free internet without government intervention. when you look where the internet has come and is going into the future, this is all being done on the private sector. >> why would he not want their team exposed the product, brand, exposed to tens of thousands of people?

so we think this blackout rule is obsolete. the fcc took the first move. they will vote finally at the end of this year. .. >> new york democratic representative brian higgins and colorado republican representative cory gardener tonight at eight eastern on "the communicators" on c-span2. >> on friday, the council on

american islamic relations held a meeting on israel's compliance with international law and its treatment of civilians in the gaza strip. a teenager who recently turned to the u.s. from israel after having been arrested and detained by israeli security. this is an hour and a half. [inaudible conversations] >> ready? good afternoon. welcome to this capitol hill briefing organized by the u.s. campaign to end the israeli occupation entitled "is israel complying with u.s. and international laws: examining israel's impunity in injuring

and killing civilians in the gaza strip and the west bank including east jerusalem." my name is josh rupner, i am the policy director for the u.s. campaign to end the israeli occupation, and we are extremely glad that a number of organizations have joined in helping to organize and to cosponsor this event this afternoon including american muslims for palestine, the council on american islamic relations, defense for children international palestine, jewish voice for peace, national lawyers guild, peace action, the rachel corey foundation for peace and justice and the u.s./palestinian community network. we're hosting this briefing, obviously, as everyone knows at

a time of sustained and disproportionate use of force that's being inflicted by israel on the captive and beseeminged and -- besieged and occupied 1.8 million palestinian residents in the gaza strip. and as we're gathered here today on capitol hill, i think it's incumbent upon us to ask ourselves whether israel is following the tenets of u.s. law when it comes to its use of force against palestinians in the occupied palestinian territories. the arms export control act strictly limits the uses that u.s. weapons can be used for by foreign countries to legitimate self-defense and to internal security, and our panelists will be addressing whether, in fact, these weapons are being used in

this manner or not. we've seen israel bomb and damage more than 160 schools and hospitals in the occupied gaza strip over the past three weeks. the u.s. foreign assistance act states very clearly that any country that commits systemmatic violations of human rights is ineligible for any form, any form, of u.s. aid. and we know that the leahy law, which is part of the foreign assistance act, cuts off any u.s. aid to units of any foreign military that engages in human rights abuses and individuals who do so are restricted from gaining access to the united states by being denied visas. the question before us is are we

a country of laws, are we a country which is going to insist upon the application of the very laws that were written this these halls of congress, or is israel somehow above the law and free to neglect the restrictions of these laws? we'll be examining these questions, and for congressional staff we have more information about this very issue for you to take back to your offices. and to elucidate both from personal experience and from professional expertise the use of force that israel employs against palestinians living under military occupation, we have a very rich lineup of speakers to the address us here today. i'll introduce them all at once at first, and then they'll come up and speak in the order in

which they were introduced. first, i would like to introduce turiq, a palestinian-american teenager from tampa, florida, who was viciously beaten by the israeli police on july 3rd of in this year in jerusalem in an incident which was caught on video. he will share with us his experiences going through that. joining him is his mother, also to the left, followed by hassan shibley who is attorney for the family and works for the council on american-islamic relations in florida. after that we will hear from brad parker, to my right, who is an attorney and international

advocacy officer for defense for children international palestine to be followed by sanjiv berry who is the middle east and north africa advocacy officer for amnesty international usa. and then rounding out the panel will be author leyla haddad who is the author of two books and is a former correspondent for al-jazeera english based in the gaza strip. and because we are running overflow, we'll be repeating this conversation at 3:30 for those who were not able to get in and who can come back later. so without further ado, i'd like to ask tariq abu hadir to come to the microphone. [applause]

>> good afternoon, everybody. i'm really happy to be back safely, safe and sound. when i traveled overseas, it was really tough. i've been through a really tough time. as i arrived in the airport, i was actually in the airport. they kept me in the airport for ten hours, so -- and, and still today the palestinian people are are suffering. and i actually visited there for six weeks, and what i've been through is just a small taste of what they all go through. and the palestinian people, they don't have rights, and they're not given, they are not given their rights. and to tell you the truth, over there, when i visited over there, i actually forgot that i had freedom. and for my cousins, i really wish they had the same freedom that i have living in america. and now that i'm back safe, i

really appreciate all the freedom and rights that i have and am given. and i'm just a kid that was born in baltimore, and i moved to tampa at 1 is year -- 11 years old, and i'm 15 years old now, and i'm going into the tenth grade. and when i arrived in palestine, it was is hard to believe what they've been going through. and my first friend over there, the first friend i made was muhammad, the one that was murdered. and the day that he was kidnapped, it was really tough because i passed by him, and i asked him a question. i was passing by, and i asked him did you want anything from the bakery? because me and him were close friends, he was my best friend. so i asked him if he wanted anything from the bakery. he's like, yeah, sure. i go to the bakery, i come back with a piece of bread, nice piece of bread, and i find the

police there, and i don't find mohamed there. so i'm really worried at this point. there's something wrong, this has to be something wrong. and then i found out he was kidnapped. and at that point we were losing time. like every second was important. it was really tough at that point. and i was really -- at that point i was scared for his life. i was scared that they were going to do something that was very, it was going to be hard. so, and when we found out that he died and he was murdered, he was stabbed and burnt alive. and it just made us think of, like, how could they do that? how could they do that to a person? like, i don't know. so later on that day to each make it worse -- to even make it worse, they taliban to shoot at -- they began to shoot at the whole city. they began to fire at everyone rubber bullets.

and they hurt. so later on that day i was on the side in an alley down the street from my house. i was in an alley, and i was watching the protest. and at that point i saw a couple people screaming from the left side of me, and they were screaming, like, a bunch of words. behind them i saw soldiers. so i was, i was afraid myself. i was frightened, and i was shocked. so everyone panicked and started running because the soldiers were running towards us. and we ran. some people ran out of the alley, and some people jumped the fence that was in front of us. and i jumped the fence, and i kept running for a little bit farther until the israeli police grabbed me from behind me, slammed my face into the floor, zip tied my hands behind my back and started to kick and punch me in the taste and in the ribs. i later on, after a little bit of them beating me, i later on

fell unconscious. so i had no idea what was going on after that. well, i felt the beating for the beginning of it. then i woke up blindfolded in the jail. they took me to jail right away with no medical treatment, nothing. so at that point i was so, i was -- i didn't know what to do. i was confused, and i was in so much pain. they didn't let me, they didn't take me to the hospital until after six hours into the jail. like, my -- i heard that my dad was out of the jail and trying to get me to a hospital, nearest hospital so i can get to medical treatment, but they wouldn't let him, like, they wouldn't let me go until after six hours. and they returned -- they made me come back to the jail after a couple hours in the hospital. so i stayed in the jail for four days. and after, on the fourth day, i had a court date. i went to the court date, and they sat me in a room for six hours until they took person by

perp for their court date. and it was my turn, and i actually went. i waited six hours, almost fell asleep in the room. so i go, and i met my parents in this room where i saw a judge and a couple other people. there was a translator right next to me, so she translated everything to for me because they were talking hebrew. then they released me on house arrest. they put me on house arrest for nine days. i had no charges from the very beginning. i was never charged. and right when i left palestine, the day that i left palestine, they raided my house. they raided my family's house. and they took my uncle and my cousins into custody with no charges. and i really want to thank all the supporters that supported me and made me, made me feel so thankful that i'm american. and i'm really sadr for my cousins that are -- sad for my

cousins that are still persecuted in israel. i have three cousins that were arrested with me. they were taken to jail with me, and their names are karim, muhammad and mahmoud. they're still in jail right now because they're not american like me. but it doesn't matter. all people, all people should be treated equally. we all -- we should all have rights, was we're all -- because we're all humans, and we were all created equally. we deserve to have rights. we deserve to be treated equally. and i think my cows sips should be treated with the same rights that i have because they should be treated with the same rights because of how israel treats the israelis with those rights. so they've been going through a tough time. so if the israelis would give the palestinians the same rights that everyone is given these rights, then there could be a possibility of peace in the middle east. i pray one day my cousins will

feel, will won't feel scared to walk outside to be with their friends, to play outside and not to be scared to be, like, to go to the store and to have fun, just continue life and be a regular human. well, i don't want them to be scared, so thank you, everyone. [applause] >> good afternoon, everyone. my name is suha, i'm the mother of tareq. i cannot tribe the pain that i felt seeing my beloved son held in an israeli prison without charges, denied medical care and suffering from a brutal beating given to h