there. >> i want to encourage all of my panelists to join in the conversation, interrupt each other, argue with each other. already we have seen some difference of perspective with regard to what is going on with voter id laws. and as we know in this session for all of you as elected officials, there's a tremendous emphasis on increasing voter turnout this year, 2014, in the midterm election. people are looking for that kind of increase. in fact, today, naleo has announced that they project that is going to be an increase from 2010, the last time with midterms it was 6.9% of the latino vote. this year, 2014, the expectation is 7.8% of a latino vote in the midterm election. so when i look at it that, mr. attorney general, i'd say there's more vote coming, but

what if those people are unable to vote? >> at me be clear about this. i want all of her people to come out and vote on election day. republicans are worried that's going to happen, then they need to change the message. if they feel like they can get the hispanic vote, and republicans need to re- message. [applause] but i want all eligible hispanics to come out and vote on election day. >> this is a bipartisan organization. the question would be is if the case to you as a republican that you think well, maybe ms. wilson is right baggara people who fear sharing power. there's no question of that and i think some of the resistance, perhaps a lot of resistance within our party would suspect immigration reform. people are fearful the way our country is changing. they are even more fearful of the fact that it's change with any kind of thought or break election for guidance from our leaders. and i think that's been the

source of some the problem we have with respect to not making progress in immigration reform. i think here, it's understandable. they need for better to educati, better understanding amongst our groups in order to make progress in this area. >> ms. wilson. >> what i'm curious about is yesterday in congress they had a vote on the voting rights act which was good did last year, a part of it, by our u.s. supreme court, which is also i guess conservatives guided it. but why is it that when it took the vote, not one republican voted to allow the hearing go forward or for there to be a vote on it? all of the republicans. and that voting rights act when it was first passed it was bipartisan. it's been there for almost 50 years, and now all of a sudden the game has changed. you would think that a country

that goes around all over the world trying to spread democracy counted even get it right, right here at home. [applause] >> and but it sounds like you think you know the answer. >> well, the answer is let the people vote. >> no, no, no. i think you think you know the answer with regard to why not one republican would vote to reauthorize the voting rights act. >> yes. >> and what's the and to? >> the reason they're doing it is because the people of color, minorities vote for democrats. they want to suppress those votes. that's the only reason. >> attorney general consoles, how would you respond to? >> well, let me -- it's not place to speak the republicans in the congress or in the senate. and i don't know which legislation you're talking about. i think you're talking about revising the provision of the

voting rights act which is in section four which was struck down by the spin court in shelby case. >> that's right. >> it could be as simple as, the republican form of which is a predicate for the department of justice being able to enforce preclearance requirement. maybe the republicans are sending unhappy with that formula. i don't know. they don't consult with me anymore. [laughter] but i don't know the reason for that but that's what we're talking but here is the supreme court struck down a formula that was based on racial demographics in 1965. the court said you can't do that. you've got to update it. there's an attempt by congress to update this section to allow the department of justice to impose these preclearance requirements. >> ms. huerta, when you hear the things about limiting the number of these people can vote, limit the hours at precincts are open, does it strike you as punitive, or do you think, well, no, if

it's for everybody, that's fair? what you think? >> i think it is there and it is voter suppression and we need to change that. we need the same loss for need the same lost forever stay in touch. one thing the republicans really need to understand, look at this figure. every single month in the training of america, 73,000 latinos reached the age of 18. let me repeat that. every month in the united states of america, 73,000 latinos reached the voting age of 18 years old. that is something that they need to look at. when we talk about the power of the latino vote, the governor of virginia's campaign, terry mcauliffe, he won with 53,000 votes. 63,000 latinos voted. he won with the latino vote.

and because his opponent was very anti-immigrant. harry reid when he went for the senate and nevada, he endorsed immigration reform. he reached out to the latino community and the latino community pushed him over the top in the state of nevada. so they need to take note. the more they attack immigrants community, because when they attack the immigrant community, they are attacking me. my great grandfather was in the civil war in the union army, okay? i was born on this side of the border when they took that border, okay? [laughter] but my children and my grandchildren, they get the attacks because they happen to be brown. they've got to understand that everything they come out and attack our community, our community gets very angry. this whole thing about immigration reform, i mean, all they have to do is set it for a vote. boehner and mccarthy, sable have a vote on immigration reform. 75% of the country supports it.

60% republicans supported. give us a vote. that's all we're asking. they've got to do the job. the more they continue to attack our community, the more people will become democrats and they've got to change their methods. the other thing is that all the pollsters of show the latino community, they love obamacare. they love obamacare because millions of them are uninsured. they also love big government. they think the problems we have in our society, that we need government to to the. so the republicans are on the wrong side of the messaging right now, individual is going to catch up to them. i don't care how much voter suppression that they do. eventually people will be able to vote no matter what. [applause] >> you said it's up to boehner and mccarthy. and that's on the republican side in the house of representative we worked together a few easier you would've said bangor and can tour but, you know, -- boehner

and cancer. one of the issues that his opponent used against him was that he supposedly was for amnesty spent okay, but we look at the election but they only had 8% turnout to begin with. but look at lindsey graham's election. lindsey graham won his election and he is from the trees for immigration reform and the defeated all of his tea party opponents. so they're using that now, okay speak with you don't think it was a real issues they? what i'm going to say, you want to get immigration reform, we've got to call on our corporate bodies, okay, to help us. i'm going to use this as a kind of comparison. in arizona when the legislature passed the law that they're going to let public places discriminate against our friends, the gay community, all

the corporations jumped in right away and said to the governor, don't sign that bill, right? they jumped in immediately. we love our gay community, i'm on the board in california but hey, we are a lot more people. l.a. kings can we are a lot more people. [laughter] where are our corporate buddies at no? we need them to go to talk to the republican congress and say you need to vote for immigration reform right now. we are not going to give up. [applause] >> attorney general gonzales, i saw you nodding a moment ago when we're talking about what happened to eric and in virginia. >> i agree. i don't think immigration was that a given issue in that race. let me just say about immigration reform. my perspective is congress, i agree congress needs to do it soon. as uzbeks have talked about, law

enforcement and security, economic issue. this is about us but this is about erica -- america and that the republicans say wait a minute. we don't want to go down this road because this president is only going to enforce the laws he wants to. my perspective is, congress has a job to do the if the president is not doing his job, they ought to be doing their job. they ought to pass the bill and both branches ought to be working together. so to me it's intolerable. i don't how hard this is to president bush tried and couldn't get it done with the republican congress. but that's why we elected people to go there, to tackle the most difficult issues we have in the country. they should be accountable. they should be accountable. >> but what your position is, it's so interesting to me because obviously there are republicans, people inside the party who just are resisting it. especially the talk radio crowd who say you are rewarding people

who have been illegal things. so you are in a position year on intraparty civil war within the republican party over this issue. how do you see it playing out? >> i think in the end my side will win, or it's the end of the party. >> the end of the party? >> yes. that's the way i see it. >> really? >> yes. i think this is something that's got to be solved. and truth of the matter is hispanics are growing political force, and if they feel like the republican party doesn't anything for them, they will vote for democrats, republicans are not going to win the white house. they will lose control of the house. won't went to the senate. so i think this is an important issue. i really do. i don't know what republicans are waiting for. we went way off in civil rights. i don't know what republicans are waiting for. it's as if they're hoping something is going to change that's going to allow them to

get what they want with respect to immigration. this is such a hard issue that both sides have to give. no one is going to get everything they want. so there has to be compromise. i do know what they are waiting for. >> i was struck of music into the party. in 2016 election of some latino vote for republicans is very difficult to see on the map how republicans can win the presidency. >> i think it's going to be a challenge. >> ms. wilson's? >> that's not my area. >> we've got you here on the hot seat so we're turning up the heat. [laughter] >> ms. wilson them what you think about this idea that unless the party deals with voter disenfranchisement issues, immigration reform, the republicans are having a troubled future. >> i agree. that's going to happen. and if i may say, it wouldn't be a bad thing to me last night. >> you are a democrat.

[laughter] to bring it back to point about increasing -- [laughter] -- voter turnout in 2014, can people like these elected officials here this afternoon, delores, use of these issues to spur hispanic voter turnout? >> i think of a lot of work to do, number one. real education is a big issue right now. my organization, by the way we are on the web, and we're funny this issue right now because the expansions of african-americans, 500% of the norm, latina, 300% above the norbert is one of the issues we're fighting right now. the other thing that's scary, they don't teach civics in school anymore. so young people don't even know why they should be voting in the first place. if we wonder why our people are nothing but because they don't

understand the importance of voting. we've got to get out there and in the latina committee would have to be invited, right? if someone doesn't invite you are not going to vote. i would say to the public officials we have a lot of power industry but i was talking latinos and other young people are going to be turning 18. we should have voter registration in high school, okay? okay. that should be constant. we need, give kids credit to god for a knock on doors to get out the vote. that was my experience. leadership is going up and knocking doors. that's what came to the home of a family and saw the poverty they were living in. that's what quit being a schoolteacher to become an organized. going door-to-door and -- knock on doors. we have the vote. we have to really make democracy

work. we are going to have come we cannot have a democracy when we have over 50% of the people not voting. these local elections are important to the school board elections are important. we want our kids to know the contribution of people of color, of the chinese. when we were -- the election, he said we are at the governor's mansion in virginia. this is the oldest governor's mansion in the united states, and it was billed by thomas jefferson. i said no, it was billed by his slaves. right? it was billed by his slaves. [applause] this is the history that all kids have to know. the contribution of the chinese and the mexicans who built the railroads and all of the contribution people of color made to this country because they don't know that. we can do it. we have the power right here in this room, right in this room. all over the country so we can

instill some of these practices to make sure people vote. [applause] i'm a republican as you know. [laughter] and i'm proud to be a republican for many reasons, and we have had, we've had some great republican leaders in the hispanic community. george w. bush was extremely popular because he had the right message, the right tone. he was the right messenger quite quickly. not that the hispanics agree with all his policy but they believed he believed in them and understood them. that comes from, part of the comes amid a governor of a border state. state. i think it hurt the hispanic community to have one party or once a dominant party, the other party is really meaningless. i think you need to have two competing parties that don't take the hispanic community for granted. they ought to be competing for our vote. i think it's very important.

>> good point applause back. >> -- i want to conclude on this message, on this question is about turnout. because we want to see more people participating in the democratic process, essential element of that is the vote but when you look at it, let's go back the last presidential election 2012, 66% african-americans or not. 64% white americans turn out. when you come to the hispanic community, 48%. we can do this with midterm elections as well. why isn't that you see in the mindset of the latino community a lack of this enthusiasm for voting that you see in other communities? >> for the last 60 something is going door-to-door getting people to vote, a lot of people

don't know how to vote. they are afraid they're going to do the wrong thing. so there's this long bout with always think that they don't know and propositions, center. so we hav had to say to them, ve for what you know. if you don't have the proper information, a lot of confusion and you don't want to do wrong thing for the just don't vote. that's why it's important to our committee and the people in this room that we act like to go out there and educate people how to vote. if they vote one time, just one time, they will continue to vote. we can do this work but it takes a lot of liquid. you're not going to do it on television to you're not going to do it on tv under not going to do it on radio. you've got to go into the neighborhood. my organization does come we go door-to-door. we have actually enable to activate over 10,000 voters just in the areas we work out. if we had more money we could get more organizers and go into more committees. people will vote once they understand the procedure and process and are not afraid.

they just don't want to do the wrong thing and that's why they don't vote. they have to be invited. >> attorney general, do you think in fact if republicans did a better job of outreach, to speaking to common interest with the latina committee you could inspire more latina to both? >> absolutely absolutely. i think the party gets that and they're working very hard to address it. but it's a dual responsibly. i think citizens have a responsibility to care about how things are going to come out and vote, get educated about what's required. i also think it's the responsibility of the candidate. they should be inspiring, reaching out to the hispanic community. there's a responsibility with the electorate and with the candidates running for office. ..

janitors and housekeepers, the concession workers that went door-to-door in los angeles. kamala harris was a wonderful woman. she was elected by 3000 votes or something like that. some kind of teeny-weeny amount. people didn't want to vote. they were mad. they lost their homes. they lost their jobs. some of their friends and relatives were deported. so we had to really pull them out and say it's important for you to vote. we did get them out to vote. at least it was pulling teeth to get people out to vote. so proposition 30 in california, the reason we are now in the state of california because we passed proposition 30. we passed a law that millionaires have to pay 3% more in state taxes. so we are able to bring in over

$6 billion into the state of california. most of that went to education. how did we get that? we had to go door-to-door, phone banking to get people to vote for that. the people we went to, interesting, to get the margin of victory, it was the voters that don't always vote. the immigrants, and people who were registered and didn't vote before. it can happen but it takes an awful lot of work to make it happen. [applause] >> so on this 50th anniversary of the civil rights act, next you're 50th anniversary of the voting rights act, i want to thank our panelists for helping us to put our place in history, and help us all to understand our role in a continuing effort to make democracy alive in america. delores huerta, alberto

gonzales, lei-chala wilson, thank you very much. [applause] >> tonight here on c-span2, watchable tv in prime time with a focus on immigration. beginning at eight eastern with a panel discussing the situation along the u.s.-mexican border. >> over on c-span tonight, this year's western conservative summit with tea party patriots cofounder jenny beth martin, sarah palin who calls for impeachment of president obama. >> these days year all of these

politicians are denouncing barack obama saying he is a lawless commitment as president and ignored court orders and changes law and refuses to report loss he doesn't like. that's true but the question is these politicians, what are you going to do about it? >> let's call their bluff. i'm calling their bluff that we need a little less talk and a lot more action. there's only one remedy for a president who commits high crimes and misdemeanors, and its impeachment. >> watch all of this year's western conservative summit hosted by the university in denver. tonight at eight eastern over on c-span. >> voters are heading to the

polls in four states today can including michigan, washington state, missouri and kansas. to select their party's nominees for the fall general elections. tonight we're tracking the senate raising kids is where incumbent republican pat roberts is facing up against tea party are milton wolff. the polls close at 9 p.m. eastern. and tonight we'll bring you life results in the kansas senate race as those victory and concession speeches. over on c-span. according to the simpson project, the u.s. and cartridge to point to many people, more than any other nation. officials take part in a discussion on the costs and challenges in delivering health care to the growing prison population. hosted by the alliance for health reform, this is one hour 45 minutes. >> your attention please. i don't want to interrupt yourto

lunch munching, but i'd like to get us started i if we could hae a lot of ground to cover, andges some great people to hear from. i know i'm looking forward to that. my name is ed howard. hear i'm with the alliance for health reform, and i want to welcome hou to this program on behalf ot senator rockefeller, senatorome blunt, our board of directors. l the program concerns the health of people in prisons and other correctional facilities and theh health care they need facilitie health care they need and the health care they receive, which may be the same and may not be the same. if you're concerned about getting proper care to those who need it, then how those behind bars have access to care should be important to you. and if you care about state

budgets, you need to care about prison health. states spent about $8 billion on correctional health care in 2011, which was about $1 in six of their entire correctional budget. that level of spending shouldn't be surprising. this is not a healthy population. it includes a lot of folks with chronic conditions, with mental illness, with addiction disorders, and it's getting older as the population ages. so it's not surprising that states are trying a whole range of different strategies to get a handle on correctional health spending. everything from contracting with third parties to deliver the care to having more services delivered on site, to taking

advantage of new health coverage opportunities for inmates. so today we're going to take a look at how well those strategies and some others are working and what kinds of policy changes might be helpful to improve both thequalit and and as we examine these issues come we are pleased to have as a partner in today's program, the thinking corporation which contract to provide medicaid coverage in a dozen states operates a number of related services and later in the program you'll hear from dr. turney was a physician from a tennessee joint venture that provides correctional health care in which centene is a partner. want to do a little housekeeping before we get started. if you want to tweak, that's how you do it with the hashtag, #prisonhealth but if you need

wi-fi in order to tweet or do anything else, the credentials are on the screen. feel free to make use of them. there's a bunch of good mature in the packets that you received when you came in, including biographical information about all of the folks on our speaker list, 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. all of that is on our website, allhealth.org, and particularly that one page you should try online because you can click on those things and you don't have to worry about copying along the url. is 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 are watching on c-span, you can find all these materials and the slides on our website, and you can follow along if that d like to do. words 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. to our microphones at either side of the room that you can use to ask it in your own voice. and you can tweak us a question using the hashtag, and we will monitor and get up to the dais. the only other thing i would ask is that as we go forward, that you fill out the blue devaluation form that's in your packet so that we can improve

these programs as we go along. and cover subjects and have speakers that would be of most interest to you. so 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 have a chance to ask questions after each one. first were going to get an overview of the issue and then turn to a view of these issues from some people who understand them from firsthand 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 are going to start with steve rosenberg who is president and founder of community oriented

correctional health services. is very pronounceable -- >> cochs. >> all right. those of you have been going to richmond to watch the redskins begin tryouts understand that coaches are important. steed of them working to ensure health access to multiple populations for more than 40 years and provide technical assistance to correctional systems towards that end. devereaux is the executive director of returning citizens united here in d.c. with 20 plus years of experience supporting and advocating for those reentering from incarceration. shields a masters degree in human services and spent several years and incarcerated herself some time ago. .. 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 practices in states working with the federal government and states working together to have a better outcome while people are incarcerated and then when they transition out into a state -- 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 build as many and as sturdy bridges between community and corrections as we can. >> okay. bob, last question. >> bob gris with the institute of social medicine and community health. i remember when senator wolford ran for senator from pennsylvania and made a big case about prisoners being one with

of the only populations in the united states that had a right to health care. in fact, that was based on a supreme court decision. how does that precedent not create the political power to implement the kinds of solutions that you're hinting at and haven't we learned anything from the tuskegee experiment? it seems like collecting data and not using it is a violation of -- of our civil rights. so where is that -- how does that fit into this problem? >> where are the lawyers? >> right. >> first, there are several questions and first i have to be a nerd here and correct, it's native americans under treaty and incarcerated individuals are thetwo and the supreme court case. but the supreme court ruled that the responsibility of a jurisdiction that could not be

deliberately difference to the health care needs of an individual. so, for example, if you have a lawyer going back waiting a year to get a dental appointment, well, that dental appointment was made. example, deborah, waiting a year to get a dental appointment. that dental appointment was made i wasn't deliberately indifferent to that person's need and i go back to regulatory frameworks, okay? that if again, how we do managed care within a community setting we require a certain number of days after which an appointment has to be made and we require a certain number of credentialing to provide care within the context. we don't do that in correctional health at this point and we're still on an island and that's the point that we'll say over and over again this afternoon. >> all right. i don't want to cut people off, but i do want to give us the benefit of our last two panel t panelists. jacqueline, deborah, th

if you're going to be sticking around anyway, maybe we'll find some q&a for the second panel. thank you so much. >> thank you. [applause] >> all right. we are reconstituted panel wise. you've heard from steve rosenberg and the other panelists on my right, dr. sharon lewis who's 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's responsible for delivering adequate and cost efficient care to the inmates in the georgia correctional system. next to her is dr. asher tierney of tennessee which is a joint

venture of centine and mhm services with which tennessee contracts to provide health care services for its correction l system. dr. turney is board certified in occupational medicine, and he's got a special interest in health inequalities and the health of vulnerable workers. welcome to both of you, and i would ask -- i guess we've, 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 tell folks that i have 55,000 bad kids under my care. what i'd like to do is to give you an overview of the georgia department of corrections which i think is a reflection of a lot of other correctional departments throughout the united states.

fortunately, we have had lots of success in improving the health care that is being delivered to the inmates in our custody and fully respect the estelle v. gamble ruling with mandated health care. to start out, georgia has a little bit of difference here. we're the ninth largest state in overall population, but we're the fifth largest prison population. we have roughly 55,000 to fenders in prison -- offenders in prison and about another 145,000 probationers. 94% of our population is male and 6% is female, and i think that this is, again, a reflection of other states. the male population, unfortunately, has a predominants of african-americans. 62% of our population is age 25-45 chronologically, and i'll speak a little bit more in just 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 are prisons. we also operate county and private prisons, transitional daycare and day reporting centers, probation detention centers and boot camps. and, again, we're responsible for producing constitutional, providing constitutional-mandated health care. does everyone understand what that is? it means there are basically three minimal standards. one is that all inmates have the right to access care. secondly, they have the right to care that it is ordered. and thirdly, they have a right to professional opinions 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 offender demographics are such that 37% of the inmate population has significant chronic illness. that number by percent is up after about four years. four years ago it was about 33%, and i think that every state is challenged with this, where they have an increased acute and chronic disease, and the diseases that are most prevalent are hiv, cardiac, hepatitis c, chronic obstructive pulmonary disease, mental illness and cancer. 17% of the georgia population receives mental health services, and there's some difference with that. in the female population, 50% of our female population is receiving mental health services compared to about 12% in the male population. and we think that's attributed to cultural differences, and then mostly in the female it is bill disorders -- behavioral

disorders, it is the mood mood disorders. we have most of our inmates we say chronologic age, their fizz logic age exceeds that because of their lifestyle prior to incarceration. they have nutrition defission says and lack of activity. limited access to health care and have an accelerated, you know, listing of chronic diseases. we have an increased population of aged, 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 our older 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 population and account for 47% of the claims. but most importantly here is that those that are over 65 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. here i'd like to like 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, you know, having an intake of chronic illness which includes those women that come into our population pregnant, and we're responsible for all of their prenatal care and delivery. and, again, they 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 that necessary mandated health care. the covered population that you see listed below represents the population that's covered in our general population. we have probably about 6,000 inmates who are housed in what we call private prisons. there are several prisons within

our state that take it so the cost for that is not, does not come out of our per diem there. so, again, here's our creativity. as you heard, i had a long history with managed care organizations, and whether you like 'em or don't or whatever, it's the world we live in. and they are successful. so some of the principles that those managed care organizations have used we have applied in the department of corrections. the first one being, and i'm very proud of this, is what we call the summary of health care benefits. and 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 and is not eligible, and basically, what the insurance company will and will not pay for. but for us it lists out what services are eligible to the inmates and which ones aren't. and it kind of puts everybody on the same flaying field

because -- playing field. and also the providers of those services understand which services are eligible. and be to give you examples, we don't pay for umbilical hernias, for outties. we don't pay for cosmetic surgery. we don't pay the treat your acne or your 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 other medically-necessary services -- and 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 herald, you know, an ounce of prevention is worth a pound of cure, and we truly believe this that. so it gives us no benefit to

deny preventive services. we follow u.s. task force for preventive services guidelines doing routine health assessments, providing chronic illness clinics with all of the necessary medications that go with that, and on a frequency. and fortunately, we have a locked-up population. so the fact that if they miss an appointment, that doesn't happen very much. [laughter] they get to come when they're supposed to come. we have a very active utilization management department that does 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 legislatively mandated, and it's $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, under pharmacy we have been fortunate because of our relationship with the medical college of georgia now known as georgia regents to be able to have access to 340b pricing for some of our purchases primarily right now for hiv drugs. we actively manage our network, both of hospitals, physicians, ancillary services, durable medical equipment, prosthesis, occupational therapy and rehand, physical therapy, we have a compassionate release process so that any inmate who has a guesstimate life expectancy of less than 12 months from a terminal or chronic disease can be considered by our board of pardons and paroles which is the clemency entity condition georgia to be considered for early release. we have telemedicine and telepsych which has allowed us to extend provision of medical services not necessarily on

site, but through the telecommunications. we have a modular surgical unit in one of the prisons where for ambulatory surgeries we're able to take the inmates to that prison to be able to have the surgeries done. and lastly, we have a forensic unit in one of the tertiary care hospitals that was 22 beds. and the whole purpose of most of those is so that we have found the more services that we can provide behind the wire rather than sending the inmates out into the community, it is both cost can effective, cost efficient -- cost effective, cost efficient, and our first goal is to provide public safety. that is the primary purpose with that. so we do a good job, i think, in providing and getting very creative and providing more and more services behind the wire. our challenges are, again, what i'd say 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. so all the mobility issues, you know, the cancer and all, we experience that. they have physical incapacity and immobility, progressive degenerative diseases. we have an increased concentration of chronic illness, and this is in the face of diminishing budgets, you know, for health care. and with that diminishing budget, we have to get very creative because there's increased liability associated with that funding decrease. we find that we have to establish protocols of who will get treated for certain diseases because of the treatments being so incredibly expensive. we have an increased mental health burden with dimension, depression, psychosis, disruptive behavior, and the cost of the psychotropic

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

parks, etc. so the relations that i would -- relations that i would -- recommendations that i would have would be that 340b 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 act so that we're not just kind of figuring it out as we go. thirdly, that we would promote electronic health record exchange meaning that, you know, electronic health records would be able to be exchanged through all venues from the prison system, through the jails, on out into the community providers. and lastly, to expand federal funding participation for inmate eligibility to help offset some of the costs within our prison system. >> thank you. >> thank you. >> okay. thanks, dr. lewis. let's turn to dr. turney. [inaudible conversations]

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

discussion today will be a little bit wider in scope. it'll be mainly on some of the issues that we deal with in corrections. but as i said, i completely empathize with anyone that has had a circumstance like that, because that's what i went into medicine to prevent. like i said, i'm a preventive medicine/urgent care specialist. our goal was to help the underserve served. this group is the underserved. it's the same vulnerable population that often times a service at federally-qualified health care centers, this is the same pop population that needs -- population that needs access. so it's the same job for me whether i'm behind the walls or not. so i just wanted to kind of describe our situation in tennessee. i am, i am a vendor arter in to the -- partner to the department of corrections. i work for centurion which is a

company that has about 60 years of experience in managed care, also in correctional health care. our parent company, centine and mhm services provide us a lot of tools that we can fulfill the individual states' needs. we provide cradle-to-the-grave service. we provide local solutions to some of the most difficult situations that our partners face. but we also, we also use evidence-based medicine which is probably a newer term, but we use evidence-based technology, predictive modeling, innovative health models to limit disease. some issues to note. so tennessee, welcome to tennessee, everyone. we are, our department of corrections, we have 21,000

inmates across the state. roughly 11 facilities. they have small subunits, but roughly 11 facilityings. and we do have some challenges. each state has its own unique challenges and obstacles as out relates to correctional health care, and we have worked really hard to improve some of those issues and make them, make them more manageable. the population as a whole, just in general, the general population has diseases that affect it, right? and those same issues mirror in the correctional poplation often times, times it's magnified. we talked about mental health illness. you have a significantly higher rate of mental health illness, excuse me, within corrections than you do outside the walls. and we've tried to deliver solutions to tdoc that improve

those concerns. centurion has managed the tennessee contract since september of 2013. we have efficiently decreased the number of admissions to the hospital and er by treating on site, by getting in earlier with our preventive health model to decrease the need for hospitalizations and trying to set up programs where we get to patients before they have an exacerbation that requires an er run. we've also tried to install what we've done can, actually, across the state we've installed, i'm sorry, telehealth, excuse me. and just to quickly refresh, that's a mechanism by which you can use an internet connection and, you know, video or telephone to, essentially, discuss with a professional on one side and an inmate patient on the other with a nurse, have a facilitated medical visit. and it allows you to get to the patient much sooner son that --

because in the past you'd have to transfer outside the walls. so we've brought that onboard. and it also decreases the, it 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, and i'll talk a little bit more about that on the next slide. i do want to say just to kind of tag along dr. lewis' comment, managed care philosophies are improving health outcomes, at least in tennessee. so i wanted to just 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. and so we have to bring an innovative, multidisciplinary approaches. so mental health, medical, you know, legal, corrections, everyone at the table to insure that these patients get the care that they need. and our patients often times, especially in the female populations -- we'll talk about that in a second -- they have a history of being a victim to violence and substance abuse, and those do make more complicated treatment pathways. as far as unique populations within corrections, i think we all have elderly populations, okay? we take care of them whether you're inside the walls or not. but the difference in corrections is that the elderly population is physiologically older than their chronological age. so you have a person that's, you

know, the life expectancy of a patient -- a person -- a patient that's been incarcerated, i see them as patients, you know, late 50s whereas the general population is much more near 70 or 75. so it's a huge difference. and so these patients are showing up to our door much sicker than they would have been and much further along in the process of diabetic, neuropathy, whatever the worst case scenario, they come in. it's a lot more difficult issue than probably has been previously really discussed. but as far as older populations, we try to look at aggressive chronic disease programs. we're developing on site, long-term facilities, long-term care facilities to provide assistance to, let's say, a demented patient or patient that needs continual nursing care. and we're also providing hospice care. of course we understand, you know, cancer increases in

incidence as we age, and so we're having a lot more patients with cancer, and so we're trying to treat them humanity, respectfully 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 disease versus their male counterparts. we have less than 1% of the inmates in tennessee are female, but they do have a significant number of medical problems, and 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's a new concept. it's been evidence-based. it shows, essentially, you work with a group of patients inthe stead of one patient -- instead of one patient, and their experiences can then be exchanged, and they learn from the grouping. so instead of the one-to-one

doctor-patient ratio, you have a one-to-five where you can have a nice exchange. and it actually facilitates were the customer -- better customer service. we do consider about our inmates and their considerations of our health care, but it also improves better outcomes; less pre-term babies and larger birth weights. so it's a good thing. lastly, hepatitis c. and, you know, that's the elephant in the room. hepatitis c is a very concerning illness, okay? it is surpassed -- can it has surpassed hiv as the largest cause of death or highest cause of death for a viral illness as of 2007. our populations, you know, nationally 17% or so, 17 point something percent of the inmates we have incarcerated have hepatitis c, okay? one,-one in five. in tennessee it's about ten

times the general population's rate. so we have about 10%. roughly. there's novack seen available. it's not -- no vaccine available, it's not like hepatitis c, and unlike hiv, hepatitis is potential liqueur bl. potentially curable. the new medications that are available may lead to that, but they're 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, 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 their judge and jury. my goal is to provide health care for them. so, you know, talking a little

bit more about innovative programs in corrections, as we talked about earlier, you know, telehealth, we can use it broadly for various specialtieses, it decreases the need for transfer, it reduces the time of diagnosis, and it reduces the public safety risk. we also go further to -- pardon me. we also go further to go beyond just the treatment model. we look for prevention. so, you know, we as an organization are moving to more customer-driven mod to el. i think -- model. i think empowering, you know, if you look at, like, 20 years ago when managed care kind of first came around, 20-plus years now actually, when it first came around we were more focused on providers, networks, facilities. now we're 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. we have a program called nurture, a telephonic -- it can be group, or it can be individualized. but it's a teleupon the bic disease management program that provides wellness to the inmates. so for example, a patient can actually with a nurse as a facilitator speak with an expert. so this goes above and beyond just having a doctor on site or a nurse practitioner on site, but have an expert in whatever their illness. let's say it's diabetes. you'll have a diabetic expert talk to you and counsel you on mechanisms to improve your health. and it's been shown outside the walls to be very successful, and we're in our terminal negotiations to implement it across our state. so these are goals that we're trying to implement to improve the ultimate health and well being of the patients. as far as the future, the future

is reentry in some cases. and in those cases we 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 z the information -- provides the information in a efficient means to get to safety in a hospital or to a community health care center or to some other 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 an ehr system, and i think that that would be a potential opportunity for policymakers to look at finding a way to improve it. because this is ultimately, like we talked about, public health. and if it can connect to the u.s. public health system in some way where that information

before they come in can then connect to while they're in, to when they get out, and it'd be a complete pathway or a complete life cycle. that will ultimately help the patients in the long term, and that's one of our goals. like i said, centurion is a company i am completely, i'm completely in support of taking care of people when they need care. and we try to find individual solutions to our state's concerns. i want to just focus everyone on the recommendations. my recommendations for policymakers at this point would be to look at integrative methods to provide behavioral and medical care on sites before and after entry and reentry. consider electronic health records as a mechanism to maybe, you know, through high-tech or through some of the other funds that are still available find a mechanism to assist department

of corrections in goning a electronic -- developing an electronic health record so we have an ease of communication. it helps unnecessary, reoccurring medical visits because you have the information from the previous medical visit. often times docs will reorder what the previous doctor has because they don't recognize it's already been done, and they have to make a decision then because the liability's on their shoulders. so i think it's very supportive. and then 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 departments of corrections in hiring qualified professionals. similar to the national health service corp. where you have a

difficulty with accessing health care, well, they allow monies available to pay back loans, and that's how they can recruit more and more physicians, nurse practitioners you, etc. thank you. >> thanks 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 tweet. and i'd like to get us started if the folks at the microphones would forebear just a moment. >> yeah. >> if i could get, actually, all of our panelists to really talk about something that was raised earlier in the program. and, asher, you were talking

directly about delivering the kind of quality, evidence-based care that is the standard as we go forward. and dr. hue byes as well -- lewis as well, what kind of standards? we've talked about the need for regulation, for oversight of the proprietary providers of health care in prisons or the proprietary prisons providing health care. what kind of a mechanism for oversight and what kind of standards are in place that you either have to impose or live up to in the case of dr. turney. and, steve, maybe you could talk about the broader picture that go beyond the specific states that were represented here. >> well, and i think part of it just shows the alliance's gift in choosing what states to represent. dr. lewis, because of her personal background in managed care and dr. turney because of

centurion's commitment to using managed care principles within the correctional institution have demonstrated the effectiveness of bringing managed care principles. i think the question is in both instances it's a question of self-regulation that's to occurred in both georgia and tennessee that shows the kind of progress that both doctors have created. i think the larger question i'm hearing you ask is should there be some other type of regulatory type framework that would regulate correctional health within a different context, and i'm not prepared to answer that question one way or the other other than to say i think we both heard the doctors say because of their perm and organizational commitments -- personal and organizational commitments to managed care principles, 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. as to whether there should be other mechanisms, i'm going to leave that up to those of you who get to stay here in congress to figure out. >> how about the specifics?

dr. lewis, what do you do with those, with those private prison? what standards do you hold them to? >> they're held to the same standards with our sops as all my facilities within the state. we perform annual audits to make sure that they are delivering the health care by the standards that we have outlined within our standard operating procedures within the department. >> yeah, we too -- i mean, the standard of care is no different inside or outside the walls. >> right. >> so we're held to that same level of care. wade have to -- we'd have to defend it in court otherwise. we internally also do audits in addition to our state, our agency partner. they do awed kits on -- audits on a regular basis, but we also do audits to insure quality measures. and we are american correctional association certified and some

of our other contracts are national commission on correctional health care certified. and those also have rigorous standards similar to some of the quality commissions. >> is it part of your contract negotiations as well? >> [inaudible] >> actually, for -- i was thinking in terms of your negotiations with tennessee in the case of dr. turney. >> you know what, i'm not as familiar with that portion. i can get that answer, but i'm not familiar -- >> okay. steve, in addition to what we might do further, do you have observations about what the other 49 jurisdictions might look like? we got the picture that maybe d.c. wasn't right up there at the top. >> not at the time that they were incarcerated, for sure. so again, i think, ed, this is part of our state, federal and local partnership. up until now we've allowed each jurisdiction to govern the island of corrections and correctional health as they see

fit, and at times they're blessed with having someone like dr. lewis who has a personal commitment that she brings forth, then you have organizational commitments from centurion and mhm that they bring forth. i think there is no national framework, if that's your question, ed, where we have made a societal decision that we're going to make sure correctional health follows managed care principles. the typical medicaid protections that are available to consumers have not been available within a correctional health setting because they have not been subject to any of the c ms standards, quality review or anything else that's required. so frankly, in our experience, when you've seen one jurisdiction, you've seen one jurisdiction. >> okay. >> ed, i do want to quickly -- we do have, i was thinking more about contractual, and we do have measures in place that our vendor partner would look at regularly and would charge something called a liquidated damage. so there are incentives to make

sure that things are running very smoothly. just as far as contractual. >> very good, thank you. yes, go right ahead. >> yes, thank you for having this today. specifically, dr. lewis, lots of strategies i'm curious about. once you're outside of the wire, i totally agree trying to do the best you can inside makes a lot of sense in that structure, never missing an appointment, that's real. once you're outside unless you have a really strong community intervention and were able to really coordinate that care from inside to outside that wire, you know, 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 insure that those folks that are then suddenly thrown out in this community once again, freedom, and all this time where they were more successful in a structured environment, they made those appointments, how do we encourage and make sure that

once they're out, they're a part of something? thank you. >> i think a couple of things. one is that we can do a better job at trying to educate the inmates about their illnesses during our chronic care visits. so that they have an appreciation for the severity of the illness. secondly is identifying public health providers that are going to be willing to the accept those discharged inmates into, under their care. we're having some difficulty with that, but it's hard to say. the more catastrophic an illness is for an inmate, we have discharge planners who try to coordinate the care upon discharge. for someone who simply has hypertension or diabetes that's well managed, unfortunately, we're probably not doing as good a job at trying to hook the links up on the outside. but those patients that have cancer and chronic diseases,

major chronic diseases we try really, really hard to coordinate the care with appointments at least in the beginning. we give them 30 days of medication to get them started. we try probably starting six months ahead of time to identify and research what benefits that are available for them with medicare, medicaid, veterans, etc., and try to get that paperwork started so that those resources are in place by the time they actually get discharged. >> and, frankly, i would say we're seeing a major difference between expansion and nonexpansion states on this. in an expansion state, it's much easier to create that linkage out into the community because these folks are being able to come out with insurance. in the nonexpanse be states -- expansion states, the challenges that we're having in finding community providers in what's basically going to be a no-pay patient. >> great. >> just to -- >> you want to identify that?

>> i'm a lifetime public health official, and in an expansion state, and it seems to me that a real lever is, certainly, consumer education but also with the state contracting. because in an expansion state, the state is paying for corrections, and the state is paying for medicaid. so in order to coordinate those benefits on the hospital side, we're looking at accountable care organizations so that hospitals are coming out and working with community providers to make that transition after discharge meaningful and so as to avert unnecessary resubmissions. maybe someone on the panel is aware of those kinds of innovations with following the individual outside of the facility into the community in a contractual yield so that there's risk or savings sharing by the corrections officer as well as by the public health officer. so i just ask, really, the panel if there's any examples of that sort of -- >> yeah, there is an example of that in oregon, in part of their ccos they actually have set up a separate postincarceration cco

contractually which has a risk-sharing arrangement with that. that's the only one that i can think of to off the top of my head that the state has done that. i think that's a great model, and i think that's a great example we want to do. again, i think the question is that given our federal system, a federal, state and local autonomy, the question has been how do you stimulate and how do you encourage those kinds of programs? is that a central grant program, is that an initiative program? how do we do that? but, yes, i think it's an excellent point. >> it's a great panel, thank you. >> you have a question on that right there. >> oh, yes, here we go. thank you. >> hi. my name is rica, and i'm with the national association of community health centers or nacc, and my question is mainly to mr. rosenberg but anyone who has input. as a staff member, we have a thousand 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 policy at the local, state and federal level that are gray at best. the inmates are disappeared behind these walls and they're labeled criminal, and there are systemic incentives for keeping it that way. so from your experience of building success building these partnerships at the community level, i'm wondering if you have any words of wisdom and lessons learned that you could share for us at nacc while we're at this national level but then have these local member health centers that could potentially want to reach out and create these partnerships but might not even know where to start or who to contact. >> sure. so the first thing i want to do is identify a huge obstacle which i think you know about which hrsa has been up until now been unwilling to allow health centers to have a change in their scope of service to define care behind bars.

so while you have these health centers that actually may be the number one appropriate providers to go out and with providing, hrsa up until now has not been willing to allow that change for scope of service. so for those of you who are here on the hill, i want to point out that's not an insentence issue. in terms -- insignificant issue. in terms of lessons learned going forward, the number one thing is about understanding, having a community board -- you have to remember community health centers are 51% user boards. and having that community be board understand and identify that the folks behind bars are members of their community who are temporarily displaced. and be i think that is a huge educational process within the community health center movement. i think that if you look at the work of sheriff ash, one of our board members in hampton connecticut, massachusetts, who started this model, he started it by him identifying that the folks in his county jail were community members temporarily displaced. he reached out to his local community health centers and invited them into his facility to provide care.

that came from the correctional side. i think the challenge is from the health center side having an absolute educational understanding that these are the fathers, brothers, uncles of the women and children we primarily serve and that they are part of our community and as such we want to reach out into behind those barbed wires and steel walls and guard towers to figure out how we create integrated care. the samhsa hrsa initiative is another great model for that to be disseminating out to health centers. >> yes, ma'am. >> hi. so my name's amy thomas, and i work for the association of community-affiliated plans, and we represent 58 nonprofit managed care organizations throughout the country. and we have one in particular in rhode island who's working with their department, their health services department as well with the prisons to help with that handoff between, you know, the prisons and them coming outside. and i particularly was curious

if you have any research about the return on investment. you know, we're looking at this in rhode island, but any research that's been done about how the handoff actually saves medicaid, state medicaid programs money? >> right. and the answer is, no, because of data sources. so the washington state data i was able to describe the you is unique because they -- to you is unique because they merge their medicaid and mental health utilization data, and they have an index that allows them to tie that data. no other state has that data at this point in order to be able to do that research. i think in rhode island you've been very blessed, you have neighborhood health plan as a leader, atwall as a leader. we have something similar happening in the state of vermont right now where there's also an effort to try to link those systems. but unfortunately, without what we'd call in their terms the master index and some way of

tying that data together, we don't have a way of doing that and there's a lot of hipaa concerns and other concerns. they were able to do that in washington, again, because of their unique data set that allow them to easily identify folks. >> okay. we have just a few minutes left. i'm going to ask you as we go through these last couple of questions to pull out the blue evaluation form the you haven't done it already and fill be it out as you listen so that we can get some feedback on what we ought to do to serve your needs better. linda, you have a second -- >> just a very quick question, yes. i think both of you talked about hospice care and long-term care inside the prisons, and i was just wondering why can't these people be released at that point? why are they still incarcerated when they probably are not a threat to society anymore? just wondered. >> for georgia i can seek is that our clemency entity which is what we call the boards of pardons and paroles, has the

authority to decide whether someone is eligible to be to be released, and we have a very active medical reprieve process. right now we probably have about 65% of those inmates that we submit for consideration that are being granted a reprieve. so those inmates who have, as i said, a guesstimate life expectancy of less than 12 months or a chronic, terminal 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 has been recently revised to include some long-term issues that are not per se terminal, but are debilitating. to be humane. no question. >> okay.

maybe this is the last question. it's maybe the toughest. we've sort of talked around it for a good part of the conversation. what impact do you anticipate so valuety, the new hepc drug, having on correctional health care expenditures? >> easy answer is bankruptcy. [laughter] >> and, therefore, what? [laughter] dr. turney was talking also about trying to deal with a very large incidence of help-c -- hep-c population. are you going to prioritize? are you going to test everybody? are you going to allow the use of sovaldi for some subset of those folks? and how are you making that decision? >> want to take it? we're going to and have started

to prioritize those inmates and, basically, leave the decision to the gi specialist who is rendering the care. as to who is most appropriate given the financial constraints. sovaldi is a very effective drug, but to treat an inmate with fewer side effects which is the big plus for that, we were talking about it, roughly $120,000. so with that type of price tag, you can imagine we can't treat everybody for $120,000, otherwise we wouldn't be able to to treat the heart disease and the diabetes and everything else. so, yes, we do have to prioritize, we do have to follow protocol, and we are currently looking at the federal bureau of prisons' guidelines for treatment of hepatitis c. >> asher, you want to weigh in on that one? >> it's not an easy answer.

i think that we still have a long way to go with the discussion. there's not been any definite, defined prioritization schedules that have been released on a national scope. the aasld and the fbop have released some preliminary guidelines which we also use. we have an advisory committee that has an infectious disease doc or helptologist to assist us in prioritizing patients based upon their medical needs. case in point, hepatitis c and hiv, they don't work well together. so when you have both illnesses, your disease goes much faster. and so they're put at the top of the list. we'll look for worsening clinical courses, and we put them to the top of the list. or, you know, prioritizing. so i'll say that there needs to be still a lot of discussion between local, federal, pharma, corrections and public health on this discussion, and we really need to find a solution. but it's got to be a

collaborative deal. >> okay. well, if you could put that composite slide back up, dexter, i'd appreciate it. just for your use, our crack staff -- led by marilyn on this briefing -- had put together a summary of the evaluations that several of our speakers today had 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 centine for allowing us to put this program together and helping us to recruit some of the folks you have heard. i want to thank our panel, and i particularly want to recall the eloquent testimony that we heard from deborah rowe and jacqueline bey as well as the panelists you see up here, and ask you to join me in thanking all of them for a very useful discussion on a very difficult topic. [applause] >> and thank you, ed. [inaudible conversations] >> the war in afghanistan claimed its highest ranking officer today when a u.s. army general was killed during an

insider attack in kabul that injured 15 others. according to a pentagon spokesman, the general was believed to have been fatally shot by a member of the afghan security forces who was later killed during the incident. white house press secretary josh earnest talked about the attack at today's press briefing. >> the president was briefed earlier today about a shooting accident that occurred -- a shooting incident that occurred at an afghan military academy in kabul city earlier today. more than a dozen coalition service members were killed or were wounded, and at least one u.s. service member, a general, was killed. the president called general dunford earlier today to get a briefing on the latest available information in that incident. while we have made tremendous progress in disrupting, dismantling and defeating al-qaeda operations and leadership in afghanistan and progress in winding down u.s. involvement in that conflict,

this shooting is, of course, a painful reminder of the service and sacrifice that our men and women in uniform make every day for this country. the thoughts and prayers of those of us here at the white house are with the family of the general, are with the soldiers and the family of those who were injured in this attack. those thoughts and prayers are also with the families, of course, who have seen the loss of loved ones over the course of the united states' 12 years' involvement in military operations in afghanistan. many of those families are the sill grieving for the loss of -- still grieving for the loss of their loved ones, and we're determined to insure their service and sacrifice for this country are not forgotten. >> you mentioned the progress in fighting al-qaeda. this doesn't appear to be an al-qaeda attack. how concerned is the white house that this attack undermines or is a step backwards in the progress that the u.s. and our partners have made in reducing these insider attacks in

afghanistan? >> josh, i'm not in a position right now to give you any information about the motive or circumstances surrounding today's attack. there is, as you would expect, an ongoing investigation into the circumstances of incident, and so we're going to wait until there's some additional details about this incident before commenting further about the possible motive or any information about the perpetrator who was involved in this incident. >> in a broader sense then, does the united states still feel that you have made progress in stemming some of these attacks by afghan troops on coalition forces. >> there are a number of security protocols that have been put in place to insure the safety and security of american servicemen who are serving overseas. many times alongside afghan service personnel. those security protocols were in place because a couple of years ago you'll recall there was a spate of incidents in which it was clear that there were american personnel who were

facing a risk based on the conditions in which they were serving. so those security protocols have been put in place, and we'll of course review this incident to see if any changes to those protocols should be made as a result of this. but it's far too early for me to say anything about that at this point while we're still learning information about what exactly happened. i do think it's important to note that because of our efforts to wind down the war and because of the changing mission of american personnel in afghanistan, we have seen a decline in the casualty rate of american personnel there. earlier this year we went an entire month without a service personnel -- service member being killed in afghanistan. but today's tragic incident is a painful reminder that our servicemen and women are still is serving and sacrificing in

afghanistan, and they're facing significant risks to protect our country and to protect american citizens all around the globe. >> tonight here on c-span2 watch booktv in prime time with a focus on immigration. beginning at eight eastern with a panel discussing the situation along the u.s./mexico border from this year's tucson festival of books. then todd miller on his book, "border patrol nation." and the author of "migration miracle: faith, hope and meaning on the undocumented journey." booktv tonight at eight eastern here on c-span2. >> voters are heading to the polls in four states today including michigan, washington state, missouri and kansas. to the select their party's nominees for the fall's general elections. tonight we're tracking the senate race in kansas where incumbent republican pat roberts is facing off against tea

partier milton wolfe. polls close at 8 and 9 p.m. eastern. and tonight we'll bring you live results in that kansas senate race as well as the victory and concession speeches over on c-span. >> on our facebook page, we're asking whether you plan to vote to reelect your member of congress. over 2,000 comments have been posted. join the conversation and share your thoughts at facebook.com/c-span. >> now, a house hearing examining the overcriminallization and overfederallization of the criminal justice system. according to a new report from the congressional research service, there were 403 new criminal statutes created by congress from 2008 to 2013, raising the total to more than 5,000 carrying criminal penalties. [inaudible conversations]