transmission is happening, hiv can follow. what we are trying to do is help those communities ramp up prevention services. the other map shows you where programs are located in the program. you can see a big disconnect where the most vulnerable counties and where the programs are and we need to bring that prevention service capacity to bare in these counties. we have also done modeling to show how big an impact can you have on hcv transmission, just making those programs available, persons who are injecting have access to clean equipment, can have some affect, 27% decrease. if you ramp up access to drug treatment so people can help people get off drugs, that also can reduce transmission, but the biggest impact is when you put together those two interventions

together with a robust testing linkage and access to cure hcb therapy. that's what our model shows and now we look forward to putting that into the test in the field to see what are the right strategies that have biggest impact in the population. so really our priorities looking forward are to improve state and local capacity, to detect transmission, investigate the social networks so you can begin to plan prevention-interventions appropriately, assist state and local and other -- state and local health departments and their collaborators in implementing and doing research with the previous slide as the case in point so that we have the best evidence to guide what we are doing for this critical population that's responsible for the greatest number of new infectionses in the country.

but taking a broader view for a moment, what i have shown you is that we now have treatment that is could cure 95% or more of people living with hepatitis c and entrying together the right set of interventions you can prevent upwards of 80% of new infections. we have a powerful package of intervention. so the national academies of science previously known as the institute of medicine has put together a panel to look at the feasibility of setting elimination goals for hepatitis c and what's need today -- needed to reach them. that panel put out preliminary findings to show that indeed elimination of hepatitis c is feasible in the united states. and now they are hard at work identifying the barriers of which i've given you examples of and providing some solutions to reduce barriers so that those elimination goals can be achieved.

looking in the next fiscal year for our activities at cdc and the hepatitis, our priority to detect people living with hepatitis c and get them into the preventive care and treatment services that they need to establish at least one regional training and technical assistance center with those states and counties that i have shown you. working with a variety of payers and then given this move toward elimination, begin to set up some state and local demonstration process that are bringing together stakeholders and interventions need today reach those goals, and we feel that that collectively we can overcome those barriers that we have those interventions and what we are -- what our main

task now is to bring together populations that are at risk for hepatitis c, we need interventions and truly come together and eliminate hepatitis c as public threat in the united states. thank you. [applause] >> thank you, john. we are going to hold questions till after all the pammists speak, next we are going to hear from dr. michael fried, professor at the university of north carolina in chapel hill, dr. fried is the leading researcher in hepatitis b and c and serves on the governing board of the american association for the study of liver diseases, please welcome dr. fried. [applause] >> well, thank you very much. i'm delighted to be here to discuss such an important topic and i want to thank carl and his

organization to put this together. everyone should be treated. if that's all you remember about this talk, i've done my job but i will also now discuss why this is so important in the patient -- to the patient that is we see with hepatitis c. we know the top 10 list are generally very entertaining and humorous and we all get great -- great joy from seeing them but this is one top 10 list that unfortunately we don't want to be on and we see here an hepatitis is number seven as leading cause of death worldwide. ..

but over the last couple of decades what we've seen from this light, with all the great treatments available for hiv, the number of deaths associated with hiv has decreased and now more patients are succumbing to hepatitis c infection and hiv infection. this occurred by 2007 and as dr. ward showed of the projections suggest this will increase through 2036. by 2032 its estimate to be at the peak in terms of patients dying from hepatitis c infecti infection. we are still in the up tick of the disease burden.

i can tell you from what i see in my clinic every day these numbers as john mentioned are bearing out in truth. this is what a normal liver looks like. this is a live with all of us can be proud to call our own. it's a nice read healthy looking liver. overtime with hepatitis c infection or any disease that can cause chronic liver disease you see this scarring, shriveled up oliver that ultimately will cost obligations from it of liver failure, the inability to process all the synthetic function of the liver does or other complications related to portal hypertension. want unpredictable is the development of liver cancer. we are seeing an explosion of liver cancer in patients with hepatitis c who have progress to cirrhosis or advanced scarring and we are faced with managing these patients with liver cancer which hopefully can get early were we have opportunities to treat.

now, the treatment for hepatitis c is shown here, it's evolved and become incredibly relatively simple. we see on the left hand side the level of the virus which is measuring the virus itself in blood. when patients go on treatment for variable duration of time, anywhere from eight to 24 weeks depending on some of the features of their liver disease and our treatment, et cetera, you'll see the virus drops down to undetectable levels within the blood. at the end of treatment the virus can no longer be detected in the blood which is attested. attest that is attested. a test of cure occurs 12 weeks after you stop therapy. if you're virus is to undetectable in your blood 12 weeks after treatment has been discontinued, we call that a sustained while logical responds which is analogous secure hepatitis c infection. as dr. ward mentioned, that the other viral infections we can think of that once it's established as chronic you can

treat it for finite period of time and actually demonstrate sure that it does not come back. this is important we can achieve now a cure for hepatitis c. animals every person that we are treaty with these new medications. -- in almost every person. why is that so important? i showed you in using the statistics this disease will progress communications but if you achieve and sustain response or two of hepatitis c, you can break that cycle. what we see is these are patients from -- these are patients who all had advanced fibrosis. they were treated in the air of injections but nevertheless about a third of them develop a cure for hepatitis c infection. what you can see is what is liver failure, whether liver related mortality or the developers of carcinoma, those who achieved cure has a low rate of any of these competitions compared to those who did not

achieve a sustained biological response or care. remarkably what you see in the lower right hand corner is even punitive mortality, actually improve in those patients. this has been censored in a number of other studies. this is a compilation our meta-analysis of different studies that looked at this aspect of hepatitis c therapy. basically whether you have all state of hepatitis c infection from mild disease to cirrhosis or co-infection with hiv and hepatitis c. we treat hepatitis c successfully you can put all cause mortality. substantially. securing hepatitis c will decrease liver inflammation, it decreases liver scarring and stops disease progression. this will lead to decreasing rates of liver cancer, decreasing these for liver transplantation and as a nation improved all cause mortality we can measure those things with --

so we can measure those things by looking at cure rates and a comes overtime at center. which really hard to hang a number on is really the individual impact of treat hepatitis c has a specific patient. we are pleased to hear about that today. we will see patients of course have less statement and the quality of life disagree with hepatitis c, with hepatitis c cure as i'm sure you hear about shortly. the power cord. great for bearing with figure out everybody had some refreshments while we're waiting. we talked about one have married beneficial during hepatitis c. i think that's quite clear from the data and has a talk with some things we really can't

measure of value to. i've been managing hepatitis c really since the year after was discovered in 1990. the treatment advances have just been unbelievable. i'd like to take you to some of those advances over time. in 1991 whitaker called interferon the was injectable. you had to inject three times a week, sometimes every day. a.b. that about 60% chance of eight you are. we added a drug called ribavirin and increase rates to about 35% of cure. we were extended the half-life of the interferon, inject it once once a week and combined with ribavirin recover but maybe a 45% chance of cure and the most common types of hepatitis c found in the united states. we were able to take a direct acting antiviral agent that attacked the hepatitis c infection, inhibitors combined with interferon and ribavirin. the cure rates increased to over

70% which was then tested. however, these drugs have substantial side effects that patients are being treated within. petite, flulike symptoms occurred in advocate patience to get anxiety, depression. everybody get some degree of anemia and a low white blood cell count. managing patients during treatment was very complex. patients themselves had very poor quality of life as we about with these early types of drugs. nevertheless, if you were treated and are able to tolerate this therapy, you had for the first time demonstrated you could cure this disease with this relatively toxic drugs. but because there's so many side effects they were relatively few candidates for the treatment because all the comorbidity they had. they would not only these medications well. frequently patients discontinued treatment early and did not get the full benefit of these medications. as we heard around 2011, around 2013 with these new medications,

regiments that were all oral treatment for hepatitis c. you could take one or several bills for a relative a short period of time is almost no side effects and your cure rates were over 90% of all patients who got treated. this just shows you the top schematic of the hepatitis c genome and where these there's drugs affect diverse regions of hepatitis c. on the bottom table you see the commercial names that you've all heard about often on television, et cetera, magazines, they push about these medications. combining drugs from different classes that you see is how they affected a near universal cure for hepatitis c. taking drugs that attacked of the parts of hepatitis c virus and how that replicates, combining them just like they did with hiv infection, but these are specific for hepatitis c and achieving incredibly high rates of cure. we now have these regimens that

you see here, harvoni, epclusa, zepatier, viekira with high rates of care between 90-95%, sometimes higher. you'll see they can be as simple as one pill or several bills with a very few almost essentially no side effects associated with them. this is you an idea, this is a compilation of a number of studies. patients with hepatitis c. this is cure rates on the left. you'll see all most all the regions across the board approach 100% cured in patients were taking these medications. whether or not they have cirrhosis, you can select at very high rates of cure already. dr. ward mentioned about -- you're really trying to give me a stress test here today. dr. ward mentioned about the casket of care and that we have a ways to go in this. for chile we have a tremendous impact over time in the casket of care.

but, the collectible therapy skincare almost everyone access to care remains the biggest barrier in control of hepatitis c infection. we've done much better in the era of the acting antiviral agents that we did with interferon-based treatments but we still have way to go. here's a couple of examples of patients i've seen in my clinice clinic, a decent children who injected drugs until 1980, married, one daughter, insured by medicaid. a sympathetic, measure of liver inflammation isn't that great but when we look at it measure up fibrosis had advanced fibrosis, a stage before cirrhosis which gives him an increased risk for liver cancer and subsequent progression to cirrhosis. is patient, i think all of us would recognize, he's got scarred. we've seen the benefits you can have from treating hepatitis c. of course, we want to treat this patient. this patient would be eligible for treatment and all of these cities except miami beach, baltimore, chapel hill, north

carolina, or chicago, illinois, the edge as if it keeps the ago witwith chicago where there only for lunch with the for people to cirrhosis already, and anybody else with mild forms of disease are being denied by the state medicaid program. another example, 26 a woman addicted to prescription drugs and then went on to heroin, complete a drug rehab program in 2012, state health insurance, married, recent graduate from college. she completed her life around. mild fatigue but, of course, because she's on the infected with hepatitis c for a short period of time of the hepatitis c tax decades before you get advanced fibrosis, she had a mild infection, stage one on the scale of zero to four. very mild fibrosis. this person would be eligible for treatment if she lived in which of these cities? detroit, miami beach, chapel hill or los angeles?

the answer now as of just about a month ago is patients who live in florida who are on state medicaid now have done away with fibrosis restriction on being able to treat patients. this patient was denied therapy in north carolina because they are still denying treatment to those who have fibrosis. i have a patient who is completely put into the district behind her, turn her life around and could easily turn the page on the difficult chapter in her life. and yet i'm not able to give her a 12 week course of treatment, eradicator hepatitis c and to her so she can move on with her life. these are some of the challenges we face on it everyday basis. anwe look at the map and it's al over. as we've heard the good news is it is changing, but still 32 states still require evidence of moderate or advanced scarring of the liver in order to approve treatment for hepatitis c.

if you have advanced scarring you are already at risk for complications of hepatitis c and risk for liver cancer. this is just data from a clinic that was put together by our pharmacists looking at patients we want to prescribe treatment for we prescribe treatment for all patients within our party candidates, we will write prescriptions for regardless of the rules for that there is haters that they have. if we think they need be treated we were right in a prescription recognizing some of these patients will get denied and they will have to appeal the process. that's exactly what happened. the initial denials the cart and about 20% of these, 1000 plus patients were treated over a 15 month period. were able to appeal, but the ultimate still got denied. when you look at what some of us cause up to now, the most frequent reason was they didn't have enough starting. the message being let's wait until your disease gets worse

before we treat intricate hepatitis c which is not acceptable to me or any of our patients. medicare at the highest approval rating over all and medicaid the lowest approval with the fewest successful appeals. so just to summarize, the burden of hepatitis c estimates and often underestimated. cheering hepatitis c will have a definite positive impact -- cheering. decreasing carcinoma and improving the overall quote of life for patients with hepatitis c. multiple pairs exist that opportunity rich to access to all who would benefit from a cure for hepatitis c infection. all of this really must continue to be the champions to effect change and to shape policies to give us greater access to drugs for all these patients. thank you very much. [applause] >> thank you, dr. fried, thank you for putting up with those technical difficulties. the next we'll hear from dr. coster's director of the division of pharmacy at the

center for medicaid and chip services at siemens. john is a pharmacist by training and has been long involved in health care policy in washington, d.c. he's going to talk about medicaid rolls in the treatment of hepatitis c. john? >> thank you very much. good afternoon, everybody. it's a pleasure to be here. i want to call this may be the reality check the presentation, part of this webinar or this briefing today. because these drugs are very, very good, the new drug you heard about but they are also what, very, very expensive. i want to describe today for you to roll medicaid as a payer in coverage of all drugs including hepatitis c drugs because it's important to understand those of you who work in their offices, work with your states and

medicaid programs to patients, what the rules are, what the current state of coverage is for medicaid, what we've done a cms. i run the division of pharmacy for cmc is, center for medicaid and chip services. you can ask a question that medicare is a different side of the house. but medicaid is now larger than medicare in terms of number of patients that are covered to recover about 72 million individuals now. we are a very big program is important remember we are a federal-state program. there are 56 individual medicaid programs. if you've seen one medicaid program, you have seen one medicaid program. they are different. cms, we oversee how states operate their programs but in general we don't dictate how to run their programs. why is a 56? 50 states, the district and characteristic medicaid provides matching funds based on different factors, but in general it's at least 50%

medicaid pays to states for services. there's been a huge shift toward managed care and medicaid. now about 75% of all patients on medicaid are in some form of managed care. there have been great advances in therapy to treat hepatitis. medicaid programs were treating patients with hepatitis previous to the launch of these new drugs but i have talked to probably more with medicaid program directors can pharmacy program directors, about this issue over the last two years than any other issue i've dealt with. i can tell you they want to provide as much coverage as possible to patients but as many of the directors told me, if we started, everybody who have hepatitis c from the time this drug was launched at $94,000 per patient we would have no way to cover anyone else's coverage. let's first talk about the rules that medicaid. prescription drugs are an optional benefit and medicaid can believe it or not. it's not a mandatory benefit but

every program covers prescription drugs. how does the program work? for a manufacturer manufacturese covered under the medicaid program, manufacturers have to sign an agreement with the secretary of the department of health and human services, hhs. that agreement basically says in exchange for the states covering all the prescription drugs of a manufacturer tha assigned to ree agreement, then manufacturers will pay rebates to the states. this is a program enacted back in 1990, because the states were having trouble negotiating with manufacturers for the cost of prescription drugs. congress decided that we will do a bargain. states, will get access to lower prices, and manufacturers, we will give you better access to medicaid patients. a manufacturer must sign an agreement with the secretary in order for their drugs to be covered under medicaid.

they recorded a statutory rebates to the states. the states collect the rebates and the federal government gets its part of the money by reducing the match that is paid to the state for that particular quarter. these rebates are collected on both drugs provided to patients in fee-for-service medicaid, and as a result of the a portable to act now on managed-care prescription. the state is talking all this money for manufactures on rebates and in exchange the data to provide coverage access to the prescription drugs a manufacturer assigns the rebate agreements. how do states control costs? all of you are in some type presumably of some prescription drug coverage. i have found a voice health benefits to many of you may have underemployed program. we all have basically prescription drug coverage. just like medicaid, your private health insurance uses berries cost management tools to manage the cost of the drug benefit. medicaid is about in addition to the rebate program to use of

there is utilization management tools, standard, practice. talk to anybody and private sector, other government programs, these are tools that are, which is to help manage the drug benefits. things like prior approval, meaning before a drug is dispensed with patient and have to jump through hoops in order to show that drug is medically necessary for a patient. states use preferred drug lists, other private sector entities use formulators. i can tell you talk to any commercial payer, they will tell you medicaid is among the most generous covers of prescription drug there's a lot of formularies out there that are highly restricted, meaning you can't get drug sometimes a lease in medicaid. if you're a manufacturer the rebate agreement, medicaid has a covered truck although you have to jump through various hoops to get it. there's also drug utilization review. medicaid uses this cost management tools to help manage the cost and quality of the benefit that's provided.

i mentioned before that there are rebates that are also paid on prescription for dispensed to patients in managed care plans. this is a huge plus for the states as well because prior to affordable care act, states work not collecting rebates on drugs dispensed to patients that were in medicaid managed care organizations. that's where a lot of new revenue is helping ms. the cost of the benefit for individual initiative which consisted is about 75% of all patients. here's the rebate amounts that are paid to the states by manufactures. so for brand name drugs, the real expensive drugs, states are getting about 23.1% of benchmark average manufacturer price. approximately a price regional pharmacies are paying for these drugs. it's a pretty substantial rebate that manufactures are being to state in exchange for coverage of their drugs.

for generics is the amount. it's about 13%. states are getting rebates with respect to drug their covering for medicaid patients both immense care in fee-for-service medicaid. states also the ability to pool their purchasing and get supplemental rebates. this was one of the key drivers of lowering costs for states, not only for hepatitis drugs but for all drug. medicaid programs, state and federal, we don't have the ability to control the cost of launch prices of prescription drugs. when the first drunk enough to treat hepatitis c, the new direct, a dea agent, at $94,000, i think everyone was in some sort of stick about -- sticker shock. it was pretty high. we don't have, the states have

the ability control of lunch prices for prescription drugs the only when competitors come on the market do you really get the ability to pick one manufacturer against the other. in addition to the basic rebates that states get what you just described, at some point as competition comes on the market, the states are able to leverage supplemental rebates. they do that through preferred drug lists. first you had, then you had tonight and i have zepatier on the market. these are the names of hepatitis drugs. maybe we'll have another one pretty soon. once you have competition, the states can leverage that and prices can come down. prices for therapy right now are a lot less expensive than $94,000. that's why you've seen some of the states open up coverage. there are many states that have moved to zero coverage meaning you don't have to have any level of cirrhosis, s. zero, in order to gain access to the drug. others have moved from f3 to

have to. i think we're moving in the right direction with respect to access protected member the context in which this entire thing started as a the states look at the cost of these drugs and saying with all these other people don't have to manage. we just have to prioritize. the states use competition in order to leverage manufacture pricing and i think most of the states have done a pretty effective job in doing that because they pool their purchasing. they could manufactures and say we will make your drug preferred, try to give all our hepatitis to this drug if you give us a good discount and return. i talked about coverage for prescription drugs with respect to fee-for-service the with the advent of managed care you should also know what are the rules with respect to managed-care? managed-care or decisions are private sector entities that the state's contract with. semester the contract with the individual medicaid managed care organization. states are responsible for contracting within.

as part of the contract that states have to certain parameters about what type of prescription drug coverage that medicaid managed care entities have to provide. medicaid managed care companies have to provide prescription drug coverage in an amount, duration and scope that is no less than what the fee-for-service plan has. so, for example, when the things we were concerned with a cms is as these drugs will do is you had several states that have in their fee-for-service program had looser criteria to gain access to the hepatitis drugs then did manage care. and managed to or decisions cannot have medical necessity criteria that are more stringent than fee-for-service. we were concerned in certain states defer service you won't have to have have to which some might argue is in itself a restriction while many of them managed to or decisions had f3, i our standard for medical necessity. that's not permitted under our rules.

as these drugs rolled out come as a look at the price them as we heard from the states, we encouraged states because we don't get paid to states. we encouraged states to look at the coverage policies as the to do not come as more competition happened as the prices came down. back last november we got concerned about certain restrictions that some states were putting in place. what we did is we put out a guidance. we don't put out a guidance every day. the last time we put out a guidance about a particular class of drugs with respect restrictions that states were putting on was back in 1996 on hiv drugs. it does not happen every day. we heard enough from patient groups, some of which may be in this room, we heard enough from physicians and we also heard enough from states to know that while we're apathetic with the states fight with respect to cost, at some point you can't use utilization management tools

to unduly restrict access to coverage. what the guidance and said, i don't know if you've seen it but it online, you can look at it, but it advises states on the card coverage requirement and for missile restriction. in other words, we told states here's the coverage rules come here's the permissible restrictions, and we recognize the significant cost of these drugs and that the manufacturers have a role in making these more affordable. remember, it's not about price that it is about price to the price of these drugs was substantially higher than anything we've seen before. we encouraged the states to sound clinical judgment when creating their prior authorization criteria. we pointed out certain things that made is concerned. for example, there were many states were f3 and simple with f-4. only one left with f-4 which we think f-4 is totally unacceptable but even those with f3 to was little utilization data come into suggesting even if they were at f3 the other criteria for putting in place

that were serving as obstacles to we encouraged them to use sound clinical judgment. we encouraged them to work with their physician and pharmacist drug utilization review board the this board helps to create these utilization criteria for the states. the state medicaid program pharmacy directors created these criteria out of the blue. don't. they work with a local pharmacist. they try to figure out my patients can we treat, what are reasonable criteria. what we got concerned with when it became unreasonable to the extent that was restricting access to coverage. we did not tell them they had to follow those treatment guidelines because these were private sector guidelines. there are treatment guidelines that are out there we encouraged states to use. we restated the rules regarding drug coverage meaning drug coverage cannot be more restrictive or have a higher medical necessity bar than in fee-for-service the these are some the things we said to the states. estate for sticking access,

contrary to such to requirements that were imposing conditions that make and reasonably restrict access, that they should examine the benefit to providing to ensure that limitations do not unreasonably restrict access, services covered under managed-care manae should be furnished an amount, duration and scope no less than fee-for-service medicaid, and ncos have to be no more restrictive. i think we've made progress. i don't know we've got as far as we would like but for example, there are several states that are f-0 at higher score before. two states just move from f3 to have to, others are in the process of doing that. states can't just turn on a dime. sometimes the weight that work with their board. they have to wait fo for the net quarter for a meeting to change the criteria but i think we're making progress. at the end of the day we tried to work with states to encourage them to move towards greater access. the states always had to try to balance that out with the fact hepatitis drugs which another

number one spend by far in most states does consume a lot of resources and they have a lot of other patients that they have also care for. that get you some of the since at least the thinking of the states. there are certain states river still consider with respect to whether coverage policies are, we're trying to work with the states to encourage them to move further towards more access. this is just not a turn of the switch type thing. we expected it would take some time but we continu continue tor what states are doing to work with them and encourage them to increase access to these important drugs within the scope of the resources that they have. i must have just done that by mistake. thanks. [applause] >> thank you very much, john. you i think it a great job of simplifying a very complicated issue for the audience.

so now we're going to take a break from the presentations. i'm going to bring up, and please welcome this to allen thompson. deism washington, d.c. he is a patient of the medstar health clinic in washington, d.c. him and he's been living with hepatitis c. so please welcome him. [applause] >> i bet this is the first time you have done this before, and it's going to be easy. do you want to tell us a little bit about yourself and how long you been in d.c. and give some background on your family? >> sure. my name is allen thompson again. i'm a washingtonian. i was born and raised right down the street. i'm 65 years of age. i have been living with hepatitis c, first diagnosed i think in early '90s.

they said i probably had longer than that. i have other maladies. high blood pressure, degenerative arthritis and hepatitis c. it was recommended to me i my primary care physician, because of my arthritis, and had to stay off, stay in bed for weeks at a time, that i try to get disability insurance. so i did. of course medicaid came along with, now come as i said i've had other problems.

i broke my leg about eight years ago and during that time i contracted -- i forgot to ask my doctor, dr. fishbein, whether that anything to do with my hepatitis c worsening. >> but you ended up having cirrhosis of the liver. but you were never sick with your hepatitis speak with not that i've ever noticed. didn't have any complications, other than when i tried to take the previous two medications. spent it's interesting, we heard about hepatitis being a silent epidemic from some of our previous speakers. here you were living with cirrhosis of the liver and you

didn't even know it, but thank god for the doctors and the blood work and things like that. so the recommended that you take interferon, and do you want to tell us, the audience, how that's administered and how you reacted to it? >> well, i met dr. fishbein when i had contracted my second bout. i had a knee operation, replacement surgery. she also checked my hiv status at the time. the nurse assistant and her staff which helped quite a bit, they insisted, and persisted, it was months after i had gotten out of the hospital with my leg replacement surgery, that i got on the harvoni speed and what

about the interferon? >> interferon was my initial, interferon, i would say, back in the mid '90s. i took that for about two mont months. >> that is an injectable? >> i think was injectable at the time. it's been so long. >> how did you feel when you were on that drug? >> i didn't have many side effects, after testing they found it wasn't doing anything for me so they took me off. >> so you on it twice, and medicaid pay for the interferon, and it didn't work, right? >> right. >> do you know other people living with hepatitis c, and how are they doing? >> sure. i have friends who lived with hepatitis c and probably dying to buy as well. in fact, a cousin of mine, i think hepatitis c was the initial reason that they passed.

and other people that we all know like ray charles or natalie cole, they died from hepatitis c. >> so after interferon didn't work twice for you, then you you would put on one of these new drugs. that's just the pill, right speak was right. the harvoni is a pill a day. the second time i was on interferon, it was a long with ribavirin. that's when i had tremendous amount of side effects, all of them. speak what is all of them? >> well, sleepless nights. wasn't able to eat. constipated. a lot. actually it was terrible. terrible treatment your so i was skeptical when i was introduced

to harvoni, because i've gone through so much with the second treatment that i had. so i talked to some of the people i knew that had gone through treatment, and my primary care doctor said they knew it was successful. so i tried it. dr. fishbein was very persiste persistent. >> and the results so far? >> the results so far a very good. i have had no side effects that i know of. maybe a couple of sleepless nights. i was on six months, because i have been on the other to come interferon treatments. the doctor said i should have it at least six months. >> and i guess today, now you have viral suppression speak with so far after four weeks.

>> i think they can say that you about cured. so congratulations to you. how does that make you feel? >> i feel very, very good. just not knowing that i have the disease, as of this moment. they say i have a couple more months before we were really find out, but i'm hopeful. >> right. so are we. you saw the pictures that dr. fried put up of the liver with cirrhosis, and this is a pleasure for the doctors. is his liver going to look normal now after being treated? >> it actually, this card can improve. it's not going to go back to normal, but if he is an f4 it's possible he could go back to an f3. and making it will prevent further competitions, further decomposition of his liver disease. one thing we sought to be

vigilant for, if you've progressed to cirrhosis, even if you're a jerk to me are still at risk for liver cancer and that's what the recommended screening for liver cancer with liver imaging every six months. that risk is lower but it's not gone. so it's important that gets done. the good news is if you been feeling well and have not had any competitions, your likelihood is markedly diminished with the cure of hepatitis c. >> thank you. any last comments? what do you think about what you heard today about the states restricting access? in d.c. he was able, because of the severe, the severna's other disease computer able to qualify. in some states you were not able to qualify for trucks. do you have any comments on that? >> i think it's a tragedy for all people that are infected with hepatitis c are not able to

get treatment and cure. the only disease i think it has a tear. >> well, thank you very much for the courage and for being here today. and for telling your story. appreciate it. thank you very much. [applause] >> we have some time for questions. you know, and maybe picking up on the last point that we just heard about some states restricting access to only the patients who are very sick. use it is unacceptable. why is that unacceptable? >> well, i think that it's relatively easy to measure who is cured with hepatitis c by looking at a blood test. and also by look at the statistics that their overall health improves because the

scanty, was cirrhosis, less decomposition. the parts that are more difficult to put a price tag on, how people feel after their church from hepatitis c. as we've heard from mr. thompson. i have patience who live with hepatitis c for probably 30 years and actually had a liver transplant. if you get a transplant, if you have hepatitis c going in, you get hepatitis c after transplant the it resets the clock which are still affecting your new liver. we have tried multiple medications on this person in the post a transplant setting and also to recount them into a trial and just cured after 24 weeks of treatment with the all oral regimen. to him while coaches no longer living under the spectrum of hepatitis c, what he said is, when asked how he is feeling and everything he said well, he said was the first thing is able to share a bowl of ice cream with his granddaughter without worrying about it.

to him that was like a really important thing. it wasn't that we save his liver individuals. you can't get hepatitis c for sharing a bowl of ice cream, i want to stress that, but this is the thing even though we try to educate about those things, these are the things he was worked out for his family. that had a major impact on this individual. so those are the things that are hard to measure. >> thanks. so this is a question for doctor ward. i've looked at your budget, and its $34 million, division. we talked about just hepatitis c today but i think your division has to focus on hepatitis b as well and combined, it's 5 million people at least living with hepatitis b and c in the united states. ..

evaluate how well we are working, and we love to protect young children who have hepatitis and at risk adults. we work with state and local health departments to what we can to strengthen the ability to detect trends and transmission and people living with hepatitis c and helping the health departments and their collaborators and the clinical setting gets those people in the treatment they need.

based on the current budget we are only going to give money for surveillance to 7 sites in the country, 5 states that are sitting and an average of $70,000 to state health departments, 48 states in 6 cities for them to do some prevention work, that is what we are able to do now, we are always looking for ways to improve the efficiency and effectiveness of those interventions. >> thanks. i know one of our key advocacy activities is to get that number more funding so our country could do a better job testing for hepatitis in the united states so now questions from the audience. we have a microphone for the c-span audience so please

identify yourself and please stand. >> i wondered if you could talk about the demographics of people who have this disease because i believe sexually and drug use are the main transmission, can you talk about more drug use as opposed to sexual transmission and others? >> the hepatitis c virus is a blood-borne virus, exposure to contaminated blood is the biggest risk. if you look at baby boomers, only about half are able to propose a way that they got infected so with injection drug use being the predominant risk 50% chance so back in the day before the virus was discovered, there was a lot more

transmission in healthcare and other incidental exposures including drug use that could play a role. now as we shut off the route of transmission, a return of injection drug use, the large majority of patients being affected today are rejection drug users. sexual transmission is not very frequent, not on the order of hiv or hepatitis c. than other exposures like unregulated tattooing and things like that are associated with transmission and other types of drug use by sorting cocaine is associated with it. to add on to mister thompson's experience with hepatitis c, the baby boomer population, one in 4

have the disease mister thompson has, or cirrhosis warranting immediate treatment because of the risk of liver cancer and other complications. that is a very thick population. african-americans have twice the prevalence as white americans, as do american indians compared to whites for a variety of risks in both of those populations and people with poor access to healthcare, medicaid populations have a higher prevalence so one of our priorities at cdc is to help improve that care cascade in federally qualified health centers, and no access to healthcare improve through the affordable care act and the care setting, make sure those people

are getting tested and getting care and treatment that they need and bringing that together with a detection response capacity improvement in states that are seeing large epidemics. >> i did the mass, and in that, talked about between 1945 and 1965, a large number of people, with hepatitis c. any other questions? >> thank you to the panel for being here today. the alliance of patient aspects, a national network of physicians who advocate on behalf of their patients for appropriate medical care and improved therapies. and a physician associated with our alliance.

as we have been working in hepatitis therapy access working group we find compliance with these drugs being expensive is high but could you all speak in terms of what you see in your research or personal clinical experience about compliance with treatment? >> compliance is excellent with these medications. people recognize they are miraculous in being able to cure the vast majority of people who take these medications. they have been waiting for many years, simple medications with various side effects. it is important before starting treatment for patients that you do educate them, very important they are adhering to these medications. the only risk factor for failing these medications is not taking the medications. there are a few other things but

for the most part if you take these medications on a regular basis as described you have a 90% chance of being cured so adherence is quite good and that is across many different populations. we have done real-world evidence studies, the data is quite good not just -- data in the real world is similar to data in clinical trials so i think it is a message that is important, take your medication. high chance of being cured. >> some medicaid programs have restricted access to the drugs because of someone's prior or current alcohol use or substance abuse. could you comment on those? >> that is variable but some states require pretreatment drug testing or alcohol abstinence prior to starting these medications. i don't think any of those were

demonstrated to impact the outcomes of treatment like they have with interferon-based treatments which were much more regular with side effects and adherence issues so if you are trying to break the cycle of new infections, treating people who inject drugs is an important group not to overlook and some restrictions would prevent you from treating this patients appropriately. you can get reinfected. if you cure hepatitis c and still have activity that put you at risk for reinfection you can get reinfected so it is important patients understand that and break the cycle on all levels. >> this is a question for john coster. i know you are not on the medicare side. however, you see a lot of patients are now aging into medicare.

mister thompson actually lost his medicaid during his treatment because he was on 6 months and moved his medicare so this is going to cost the government and taxpayers a lot of money. my question is on managed medicaid organization, 75% of them, 75% of medicaid is management, how are we enforcing the fact that everyone you are encouraging manage medicaid to follow fee-for-service restrictions because what we are seeing is not the case at all. >> we are aware of that and that was one of the reasons we decided to issue guidance, to reaffirm and managed care plans that there are rules regarding drug coverage, the amounts going duration of coverage and managed care have to be similar to

fee-for-service and you can have a higher medical necessity criteria. states are responsible for managing and overseeing their contracts but we put on a new managed-care rule that i think will give us a little more of a hand in oversight of those contracts but it was probably 50/50, that was half the reason we did the guidance, we saw such disparities between fee-for-service and managed-care. one state, fee for service, when medical necessity for criteria and multiple managed care plans with a different set of criteria and it was a matter of equity that in law everyone should be the same. as far as what we are doing, looking at what happened since guidance went out and who

remains, which states continue to have those disparities. we don't expect -- we don't expect -- the managed care plan may cover different plan than fee-for-service but they can have different criteria then medical necessity and we need managed-care plans to cooperate because they are a partner in providing care to medications. i hope that answers your question. >> doctor carl fried wants to add something. >> right now there are restrictions in state and other payers based for economic reasons. there are no medical reason to restrict treatment for people with mild disease. you can make the counterargument that people with my disease are fantastic candidates for treatment because you will not have to worry about hepatitis c in the future. most of the guidance is out

there and i will point to one, guidance from the infectious diseases society of america commented that all patients are potential candidates for treatment and that is based on a panel of experts who recognize if you can cure these patients your preventing long-term complications and improving quality of life for all patients. >> next question? >> i work with doctor -- in regards to it would be -- it is an economic issue as far as having to pay for all patients on hepatitis c regardless of the score. still, actually worse because if you only treat patients on the economic basis, we are looking at those that are still going to

progress so technically they still have to have screenings, that will be a long time affect so wouldn't it be best for insurance companies to look at it in a broader perspective so 30 years down the road they are benefiting from it and they are not getting the acc screenings they wouldn't need? >> i couldn't agree with you more. trying to treat people earlier to prevent complications is important but it is hard to see the cost savings with such a long horizon and that is one of the big issues we have to overcome, recognizing these treatments are curative, don't prevent long-term complications and treating everyone is important to preventing those complications. >> we have a benefit we are trying to properly evaluate and

assess, we treat and cure one. how many infections are you preventing? the current models and predictions are about the benefit of curing the patient, introducing health costs and individual benefits and the other benefit is transmission to others and that is the study and demonstration process except we are seeking to develop to answer that question because you can't do that kind of chauffeur transmission. >> i have seen so many studies the talk about the cost effectiveness of treatment because people do not progress to liver cancer or liver transplant etc. which are very costly. i saw question in the back of the room and that will be the last question?

>> looking at the finance committee, to john koster, they put a report on how gilead developed the hepatitis c drugs as well as the impact on the us healthcare system and one widely reported piece of that report was there are 700,000 medicaid patients estimated to have hepatitis c and the program spent $1 billion to treat only 2% of those patients in 2014. one of the less widely reported pieces of that report as company documents showed they were setting list price in contracting strategies that the company new patient access would

be reduced as the price was increased but reduction in patients would be offset as a result of the higher price in terms of revenue so i'm curious about two pieces. do you have -- i don't know if you have updated data on 2015 in terms of the amount of spending and patients medicaid states have been able to get to this year. but secondly i know, letters to companies at the end of last year but when you send letters to medicaid states putting up the guidance you sent letters to companies and i am curious whether cms feels the companies are doing everything they can to make sure there is access are

still attention where companies could be doing more. >> that is a good point. it the same time we put out the guidance we sent letters to four companies that make these drugs, merck, j and j, and basically asked them what more they could do to make these drugs more affordable are at that time the drugs were still in the $90,000 range and states were struggling as they still are now in many cases to pay for them. we do think competition has helped bring down the price of the drug and they started at a point where they were relatively high for states and commercial payers to pay for them. i don't know exactly what that is, manufacturers will come up

with individual ways to support them. we put out a guidance on value-based purchasing which is something we are interested in seeing if manufacturers are willing to engage states on that and that is the manufacturer has some risk in this game. can't set a price to pay for any other payers say the outcome is the outcome, manufacturers have to have some skin in the game. so we hope over the next couple months, as we work with states that still have restrictions we find unacceptable that the manufacturers of these drugs will come forward with innovative ideas, prices of come down because of competition bit they come down from a very high point so i think that is the best answer i can give you right now your question because i said in my comments we don't have the

ability to control launch prices which everyone struggles, not just medicaid, medicare does. when competitors come on the market pricing can be managed better through competition and utilization management tools but the launch price has everybody vexed. the president has a proposal that could create a full purchasing system for federal and state purchasers because as you mentioned medicare buys these drugs, medicaid buys the drugs, public health service buys the drugs but we don't have a coordinated way to take them so in many ways there are many disparate purchases because we can't pull our purchasing but if there was a pooled purchasing among federal payers or at least cms payers we would maybe get a better launch price after price reduction we saw with this

particular class. >> i don't have inside information on drug pricing but by what i read in the papers you are now seeing the drugs are in the $20,000 range. i have also seen, less than the cost you pay in england, so it looks like because of competition the price of the drug has gone down. the other comment i wanted to make is i was going to ask this of you because i have seen a lot of scary numbers, you mentioned 700,000 as well in the dedicated program but as doctor ward talked about, 50% of the people in the united states with hepatitis c don't even know it so the estimates of the million people with hepatitis c in the united states are just estimates so it is not the number of

people who are diagnosed with hepatitis c. just like with hiv i could do scary math for that as well and take the $1 million -- 1 million patients and multiply by the cost of the drug and we know not everyone with hiv has knowledge of their status as well and it takes a long time, the cdc is recommending for almost a decade that we have routine hiv testing and the cdc announced at least people are at risk, the baby boomers be tested for hepatitis c at least one so like hiv it is going to be a long time before people learn their status and get treated and improve that cascade.

so we can have people with hepatitis cured and hopefully eliminate it someday as well because we have that possibility so thank you very much to all of our panelists. i would also like to thank the institute staff, frank could, nick taylor and mike drew, thank you for sponsoring today's briefing, thank you very much, please join me in welcoming all of our panelists, thank you. [applause] >> i want to add something, the medication takes 30 pills per month, $30,000 more.

>> thank you. [inaudible conversations] >> some news to add to the store, london's guardian newspaper had this article about hepatitis c treatment costing less than $300, a fraction of the $80,000 price charged by major drugmaker tested in egypt, available in two years, clinical studies already tested on 300 patients with 100% your rate and malaysia and thailand have different arithmetic and expect to be available in the next 12 months and elsewhere within 24 months. today on q and a, cia director

robert gates discusses his book a passion for leadership, lessons on change and reform, 50 years of public service, the program airs at 7:00 pm eastern. also booktv in primetime start at 8:00 with us history through the decades. the 1960s, witness to the revolution, hippies and the year america lost its mind. and howard means, 67 shots in kent state and the end of american innocence. at 10:05 the 1980s, irruption, the untold story of mount saint helens but shortly after 11:00 jacob weinberg and ronald reagan, tonight on booktv primetime on c-span2. lieutenant general jack weinstein, on nuclear integration, talks about the service branch contributions to

global security and nuclear deterrence and talk about the need to modernization of the remaining us stockpile. >> good morning, i want to welcome you to the last of the seminar on nuclear deterrence and missile-defense with the caveat that we have two possible additions, i'm trying to accommodate them as we go on. we have several war fighter events in september, one with general whitey on 9 september and the 22nd, colonel bracy, talking about the space enterprise ground, general white will talk about space enterprise vision, the 22nd, doing a triad

event, and it begins at 11:00 this morning and we will be doing a triad event, this is tentative but in indiana next march, and want to thank staff for jack weinstein, welcome our allies who are here from various embassies, and want to welcome c-span, who is here today taping this event, for those watching on c-span, the series began in march 1983 in an effort to explain, let people understand the strategic modernization effort of the reagan administration. this is only the second time to try it beyond the first go around. jack weinstein is head of a

tenant if you want to see his bio, would you i'll give a warm welcome to the director of a 10? [applause] >> thank you for everyone coming in early this morning. it is a beautiful day, the sun is out. it is a wonderful day in washington. i want to highlight a couple people besides hunter who has worked for me. and we brought marie mcclatchy, a talented individual. someone else i would like to introduce, have this person stand. cadet shafer.

and on the 5-year program. he is at iowa state and worked for us all summer. if you want to know about the strength of the united states air force you are looking at it. cadet shafer has done a tremendous job going back to school because we need to make them lieutenant and assign him, hopefully he wants to be a bomber pilot which is great. welcome and thanks to all you have done for us. thank you. [applause] >> i am excited about speaking with you this morning and the value of deterrence and touch on some misconceptions you may have read about or heard about and tackle those. the heart of our deterrent force is not our weapon system. the heart of our deterrent force is what operates them and maintains them, the airmen that support them in the airmen that

secure them. that is the key that makes the united states air force unique among all air forces on the planet. if you want to know how different we are, the responsibility we put on junior airmen to do everything we mentioned is really remarkable and the strength is our young airmen. let me tell you about the environment they work in. last week, and the heat index was over 110 ° with about 100% humidity in louisiana but we still had brave young men and women maintaining b-52s on the flight line even though it was extremely hot. that is just one day but they do that every single day. if you have ever been to louisiana it is like that from about may to september and to

the other extreme it is really cold in north dakota. you can see it on tv but it may not be the same but anyone serving in the military today, anyone serving in the military today are serving and came in after 9/11. and serving with time of war, commander of 20th air force, the weather in february was-42 °. these provided deterrent force, when you think about a deterrent force i don't want you to think about these systems, think about the airmen in all corners of the united states. i say this planet because an individual worked for me at the 20th air force who was born in germany, two germantown's who wanted to become an american citizen and support the united

states air force. that is the strength of a deterrent force that makes us unique. i want to talk about the value of our deterrent force because it underpins conventional forces and underpins the dramatic power for our nation. when you look at what the united states air force provides the nation, it is a breath of responsibility. the breadth of response ability goes from terrorism fighting terrorism as we do today with isis and al qaeda through the full spectrum up to nuclear deterrent force. our conventional forces are able to operate and support what the president wants us to do as a foundation of a nuclear deterrent force that protects our nation and has protected our nation for a long time. deterrence is more than a triad.

we talk about the triad a lot, and at one point, the triad was a triad. we have command and control and weapon systems. we talk about bombers and capability the bombers provide and icbms provided the possibility my friend in the navy provide with the slb m force but the united states air force is much greater than that because the triad includes dual capable aircraft, that is also part of the nuclear deterrent force. it includes in c-3 national command and control, the ability of the president of the united states, to communicate with forces whether it is a benign environment or the worst day the president needs the capability to talk to his forces and give guidance at the united states

air force provides that. the air force provides -- makes is a global military, the ability to go anywhere on the planet, the global military is provided by tankers and that is an item the united states air force provides and you have a full underpinning of intelligence, surveillance and reconnaissance because you need to know what was going on if you are going to make decisions and the air force provides intelligence and you look at space capability. space capability is critical whether it is on orbit satellites providing that communication piece or early warning satellites that tell us what is going on and whether the united states is under attack or not under attack. if you think of the triad, to me it is not to be looking at weapon systems that are icbms and bombers but the full gamut the takes this capability to protect our nation, protect our allies and provide that external deterrent. i would like to go back in time a little bit and go back in time

to when my grandfather was in the united states navy in world war i. if you look at the united states and the warts an end all wars, world war i was devastating and if you look at the 20th century from 1914 to 1945 that was a very dangerous time on this planet's history and the amount of people that died in that period of time was astronomical and it is tough to get our heads around what happened when major powers fought major powers. in world war i, 1.8% of the world's population was killed in world war i. then we have a break which truly wasn't a break and another will world conflict except this world conflict was much more devastating than world war i was and in world war ii it was 2.8%

of the population that was killed. totally, between world war i and world war ii, 75 million people were killed, civilians alone in world war ii that were killed were 45 million civilians. if you look at the early start of the 20th century, that was an awful time, world powers fighting world powers, billions dying, military dying and all you need to do is take a trip to europe and look at the american cemeteries and roads and roads of america's best and brightest, you will see firsthand the devastation and what it is like when world firing -- world powers fight world powers. then the atomic weapon was developed and world powers are

not fighting world powers anymore. we have had skirmishes and wars, we are in one right now and i could list all the wars that have happened from 1945 until 2016 but you don't have major powers fighting major powers so i want to be clear. any death in war is a tragedy. one person dying is someone's spouse, someone's brother, a mother in law losing a son or daughter so any death in war is a tragedy but world powers are not fighting world powers and i believe it is because of a nuclear umbrella that exists and the balance of power we have among major states that have nuclear weapons. the world was a little easy. we didn't think it was easy but it was pretty easy. it was really bipolar after world war ii. it was the united states and the soviet union.

that is not what the security environment looks like today. the security environment today is complicated, multi-forward. we can use these fancy worlds but this is a dangerous place but one thing we will come back to, how we protect our nation, how we keep our citizens safe, how we keep our allies safe, how we do that extended deterrence, we can't simply look at the problems through our own lens because deterrence is capability plus will and other nations have a vote in what that means and we can never forget that. we cannot make decisions in a vacuum. we need to understand through the eyes of other nations. the security environment. i am seeing things i thought i

wouldn't see. the soviet union came on active duty, evil empire, take down this wall and all of a sudden the wall came down and on the 90th operations group commander we host the commander of the russians rocket forces. a pleasant experience, meeting with the commander of strategic rocket forces, having lunch in a missile facility, taking them to launch control center and having discussions. it was fascinating. and i move to vandenberg air force base and have commander of the russian space force. another pleasant experience. i am meeting my counterpart and my counterpart at vandenberg, my good friend for period of time was susan helms, general helms at vandenberg, the commander was there, great discussion and all of a sudden the world changed.

the world changed when we have a president of russia standing on tv with his generals talking about his nuclear forces. kind of unprecedented. it is unprecedented for me to go to youtube and look up and exercise the russians are doing and that exercise is portrayed on youtube in english. obviously that is meant for someone other than people who speak russian. then i watched tv and islands are built in the south china sea and earlier this week we have north korea launching two missiles. one worked, one didn't. one has to work. that is the environment we have. what does a deterrent force provide you. what do you need for deterrent

force? what you really need in this whole arms control arena is not to cut weapons. cutting weapons isn't the goal. the goal is strategic stability among world powers. that is what you need strategic stability. arms control and deterrence work hand in hand. it is a partnership we are working with a good friend of mine. a close relationship because there is a symbiotic relationship with deterrence. there is framework for diplomatic engagement. it improves transparency and mutual confidence because that is what we need. we can't forget the regional deterrence and what we provide our allies by having a nuclear force because that contributes

to nonproliferation objectives of the united states and to develop nuclear weapons. and work closely with that, and that is working with assuring our allies. however, despite the value of the deterrent force, keeping world powers fighting world powers, there are a lot of misconceptions out there and they are interesting and talked about and written about and i find it interesting because i don't face it in that. they are not good for what is going on in the world. to the beginning, the deterrent forts the united states provides, and the united states air force provides are two of the three legs of the triad,

strategic stability in that balance, to operate. certainly those misconceptions, a new cruise missile, i tell you in my heart, not having a strong deterrent force is destabilizing for our nation. i have yet to find in 5000 years of history a country that is weaker that survives. providing a deterrent force is key and destabilizing and there are comments that you won't be able to distinguish between one missile and another missile even though we have had cruise missiles since we had the hound dog missile years ago. by the way, cruise missiles were recently used by the russians, develop new cruise missiles. there is also a comment that

deals with because we are modernizing our force they are more aptly used. that is completely false. when you wear this uniform you provide advice. that is what the responsibilities but the soul release is on nuclear weapons as the president of the united states, sole authority. developing nuclear weapons and everything you heard about easy use of nuclear weapons, doesn't have a leg to stand on because the only person who releases nuclear weapons is the president of the united states. that cannot be delegated or taken lightly but the president of the united states does that. then we have a discussion that talks about if this comes up every other day, we can go to a diet, and i have heard a lot of

other terms being used. when i look at the problems i can't look through my lens. i can't look through the way i see the world because i see the world as an american. i was raised in this country, some of you might tell a tinge of an accent which i'm proud of. any patriots or red sox fans in here. if you are not we will make you one. you need to look at the problems through the eyes of other nations. other nations get a vote and as i mentioned deterrence is capability plus will. what deters the russians? what deters the chinese? what deters the north koreans? what deters the iranians? what deters other nations from using nuclear weapons? that is not a question you can

answer in a vacuum. having strategic discussions about that are interesting to me but the question is what deters russia from using nuclear weapons? what deters china from using nuclear weapons and for the past, since the late 50s early 60s with atlas icbms on alert, b-52 on alert, the uss toward washington as the first ssb end, it has been the triad that has kept the peace, the triad that has insured no one believes they can wake up today, no one believes they can attack the united states because of our capability so this is looked through the lens of other nations, not solely through our lens. so what is the future going to

look like? i have no idea, none. i was surprised when the wall came down. i was surprised having a cup of coffee in baghdad in one of saddam hussein's palaces, sitting in saddam hussein's palace having coffee. i was surprised when i was having a beer in hanoi, sitting down with young vietnamese who wanted to speak english because they loved america. i was surprised when the commander of the strategic rocket force was in front of my crew members telling them how proud he was of them because of the most fundamental thing they could do. i am proud of what you do. that is strong from the commander of strategic rocket

bases. and all i know is whatever we plan future is not what the future is. what we need to do is have a strong deterrent force. the world free of nuclear weapons, but i am not naïve because that did not happen in my lifetime. as long as we have these weapons we need to be safe, secure and effective, everything we do every single day, and supports with the president of the united states is doing in his prague agenda and we in the air force are committed to maintaining what we have done since the 1960s by modernizing our forces,

modernizing our icbm leg, and in c-3 capabilities so the president of the united states has the capability to talk to anyone he needs to talk to so together i hope we all know we can hope for a future that is a peaceful world that will be fine. that will not be the future, we need to plan for the future. modernizing forces, and the strong nuclear foundation, well motivated airmen which we have today, continue to do that in the future and that will provide assurance to everybody in this room, everybody in the united states and our allies and letting other nations know that today is not the day you can attack the united states of america, you cannot do that, you cannot do that because we have

people at sea today, people training, flying the 2s and b-52s and people in icbm silos, have always been there since 1960, 1961 was the first ace in the hole. thank you for letting me talk about how i feel about the nuclear force. i think it underpins our entire national security and every single day i want you to think about as you do your normal day-to-day activities you are able to do your normal day-to-day activities and be safe in the united states of america because you are people in north dakota, montana, wyoming, louisiana, and all over the planet protecting this nation, thank you. [applause] >> questions please? thank you.

>> when vladimir putin speaks of using nuclear weapons, what do you think he is talking about? >> that is a good question for strategic command but from what i read in doctrine, using nuclear weapons in order to get my will across on what needs to happen. i believe it is using it in a conflict or in a scenario in order or whatever he is trying to accomplish gets accomplished. that is what i believe he means. >> from aviation, we won two competitions, one for the cruise missile, one for the strategic deterrent. the cruise missile is a classified program. you had the most pushback on the

cruise missile program. a classified program and using visibility to the taxpayer and secondly, it doesn't look like frank has made a decision yet for ground-based strategic deterrent. >> the question is about lrs oh, the long-range standoff and ground-based strategic deterrent. i want to turn the answer on a little bit. you made the assumption the reason we classified lrs oh, so we wouldn't release how much it cost and that is not true. the classification was done well before working through any cost data. the reason we are protecting lrs oh capability is it will provide certain details because what makes it a strong weapon is the

capabilities inside the weapon. that is what i will say about it. the people on capitol hill that control the money and the authorization and appropriation get briefed on programs of that nature and there is nothing we are hiding, what we are hiding is to protect the capabilities of that side. when it comes to gbs e, the request proposal on the streets just like lrs oh it hit the streets last week, companies are working on it right now and as you normally do through an acquisition process we have a lot of meetings with mister kendall a very intelligent individual, we are just going through what i would consider a normal acquisition process on the system. he has questions, we provide responses back but the key item, he wasn't confident in the

program, the request for a proposal has not been released. having request for proposals is extremely positive to our modernization programs. that was a key item. i recommend you talk to the acquisition folks on the specifics. i want to talk about strategy, why we need the capability. >> am i to double back -- problem through the lens of what is necessary. if i could elaborate a little bit on what do you think, trying to look through the lens, they

are thinking, when essentially they reject the notion the first nuclear weapon crosses the threshold that all nuclear weapons will then, clearly feel that they can get away with using one or two. what is the difference between the way they are thinking and the way a lot of people around here think? >> i don't think crossing the nuclear threshold is something to be thought of as something that has not happened in a very long time so the notion of one equals of thousands, i am not there yet to be honest. i am not vladimir putin so i can't answer for him but i will tell you even when the soviet union went away and russia was

in dire financial straits, they believed their nuclear force was there foundational piece of their country that made them a superpower and even though money was taken away from other forces, money never came away from the nuclear force and they always maintained that capability so to them i believe their strength is the fact that they are on the world stage and they have had a nuclear force. they have always had a nuclear force. i want to talk about something i don't want lost. when you look at the modernization piece and it goes to the questions you asked, a few years ago the russians came online and said they would replace their sillier icbms by 2021 so they have been modernizing their entire force. the chinese have been modernizing their force so the only nations that have not upgraded, i am talking about

bending metal to develop new systems is the united states. we are still operating on 1970s technology, and programs we just released will take years for those programs to come into the middle stage. i believe it is a superpower, what makes him a superpower, i do think when i say look through the other lens they have modernized their nuclear force so i don't believe we shouldn't because i think it makes us weaker. i think we need to look at this is more of a social science aspect, what deters someone from using a weapon and what deters someone from using a weapon is having strong capabilities. that will prevent people from thinking they can get away with it. the modernization piece is critical because deterrence is the weapon systems, capability plus will, deterrent is also a

mindset. it is what someone believes about you. if they believe the united states doesn't support this and we let our systems atrophy because we don't modernizing that will paint a different picture. it painted a picture when modernizing your force. we talk about that and you mentioned it briefly, these weapons were developed in our arsenal, was built up in the 60s and we had the reagan buildup in the 1980s and developed you and weapon systems. by the way, we had the triad but we modified the triad over time. when you look at the size of our stockpile nuclear stockpile has decreased by 85%. in 1991, when president bush, took b-52s off of others, killed small icbms, we have a nuclear

force of ssb ands and bombers that we can generate if needed. we did that because we know we need to deter other nations. that was a good day. having systems allows people to get to the table. if you retire systems because you think it is time to retire systems and not based on strategic dialogue with another nation that puts us in a precarious situation. the cruise missile, the purging ii was a successful weapon. it was developed, fielded, used as deterrent capability, and when it achieved its aims it went away. to me that shows the value of deterrence and what the nation is 4. ..

i think if you read even sectors of the air force talked about that. i think it's a dangers to come with a policy win which had little bit of ambiguity into the president options is the bottom line. taking off his way, i don't know what the future looks like it's out of the with the strategic of our that will be. i don't know what the exact circumstances but when you start taking things off the table that changes the calculus on the other nations be a. that's a dangerous piece of when you say no first use. it takes items off the table. when i wear this uniform obligation form to represent peace. not war your that's what i

wanted to represent your i want to represent it through strength. as some who live in the nuclear world for my entire cover your that deterrent force provides aa level of strength and a level of peace 24 hours a day. if you start taking options off the table, that's bad for future presidents when they can't do that. to meet a little ambiguity, we can go to a checklist that talks about every single circumstance that happened in the future, therefore the strongest thing you do is for other nations to know you have the capability. the president needs options. [inaudible] >> the first is the general has stated his concern that they may not be able to penetrate or survive in a post 2030 environment. so my question is did you speak

a little bit more to what the concern is the concern a russian f5 and/or 6-under or something beyond? is the concern of expansion of the moscow-based missile defense system around moscow? if you could explain, expand on that in more detail. and second, the air force has been declared the system when it comes online in the 2020-2036 timeframe of the silo-based system. the air force is did one of the objectives of the modular system approach is to offer alternatives. the question is, is the air force seeking a design not a decade or two decades from now but multiple decades in the future could be transition to a mobile platform in the event of a decision to do so? >> let me talk about that first. gbsd is a silo-based system,

period. the modularity of the system is really, really key. because when you look at the current system if you want to upgrade the command and control system, a system that talks to the missile and what the crews operate, that's not a module-based system. if you to open up that software and change it based on the upgrade you need to make, you can't do that easily. it's really expensive to do that. when you base the modular approach, there are key components you on a command-and-control site based on what the future likes that you may want to change. you can upgrade the guidance based on challenges that are in the future. it's a smarter way to think. right now everything is compacted and only way is to open it up and that's what expensive. that's that peace. the jungles comments to all i will say is when you look at the a2ad capability, when you realize what a ballistic trajectory looks like it could be challenges in the future

based on that. what you need to do is have a system that can always be with the president directs that system do. i will just kind of put onto that thing. the biggest issue in gbsd is really the modularity of the peace that i can't stress enough the system needs because effective as an all modernization programs. we need to be good stewards of taxpayer dollars and 20 develop a system we can develop a very compress cost effective as we can make it. that's really the key. as well as to upgrade in the future and doing upgrades that can be cost effective to that peace. >> there's inconsistency between thing as were a few minutes ago that it's terrible and destabilizing that president putin might be contemplating using nuclear weapons first, and saying that the u.s. needs the option of using nuclear weapons first. >> i don't think they are

opposed. i think what you want to do is you want to deter russia. we're talking to putin, we want to deter russia. if the russian president believes our policy is such that he can escalate in order to do something, then i think that changes the calculus. i think what we need to do this for flagmac going to understand that there is no way you can use a nuclear weapon and believe it's okay to do that. >> why is his first is different but our first use? >> i think the difference is, here's what i'm looking at. in this country when a candidate nuclear exercise and you will not put it on youtube and not put it in english. that's a fundamental to the way of looking at it. we also don't stand up with a bunch of people explaining about our nuclear force in a very bellicose manner nor in ukraine saying i have nuclear weapons.

we know he is nuclear weapons. i think it's a completely different look at the way the system operates at a completely different look on the way he operates. our response is to give the president options. he's going to come he or she will make the final decision of what that's like. and what is in the best interest of the united states. but i've had a couple of questions from i don't know what goes through the mind of other national leaders or international leaders. i don't know what goes in and of russia public was in tibet and china. that's not my job. but my job is to make sure from a military standpoint that we assistance that are capable enough that the other nations now that they work. i think that's the difference. [inaudible] >> that's correct. that's what he said.

there's a bigger issue. the bigger issue is the federal acquisition regs. accessory milestone a decision, the first of an acquisition process, you need a cost estimate if you need an independent cost estimate. that's where we are right now, developing, not we, that's what they do spirit that will be done by august? >> and that will be done by august. that's what mr. kendall will use and he will make the decision on the cost and that goes into decision because it's required by the federal acquisition regulations which is required by law. all of that is on track right now. that is a tough thing. as soon as you give a date everyone writes down the date and if you don't meet the date they think something is wrong. and something, that's not the way the world works.

>> i know these have been planned for quite some time to do the christmas of a ballistic missile competition, but why launch these programs before a new administration comes in next year? why not wait for them, the nix it administration to make decisions about whether to move forward with these programs? >> i'm not the politicians are not going to go there but what i will say is we have a president of the united states and he is president and tell you so longer president. right now when you look at our modernization programs, that's the schedule. we are sticking to the schedule based on which there. the new administration can determine whatever they like across the full gamut of what the military provides and to make decisions. but for right now i have a committed she. we support our commander in chief then we have a schedule to support our programs. for the schedule was released for the second is in 2016, and that's exactly what we are doing.

all right. [applause] >> thank you all for your support for the series. i now have to go back and start planning next year, which you'll hear from me, but thank you, general weinstein, for your remarks. thank you to our supporters, our embassy colleagues under military officers at our cadets who are you. thank you very much. and thank you, general weinstein, for those remarks. we will see in september for the two upcoming space events. thank you. >> today on q&a former defense secretary and cia director robert gates discusses his book a passion for leadership and lessons on change and reform from 50 years of public service. the program airs at 7 p.m. eastern your booktv primetime begins at 8 p.m. with u.s. history through the decades.

>> activist from the coalition called disarm hate gathered at the national mall last weekend to speak out against gun violence and to voice support for lgbtq writes. the rally was organized in response to the mass shooting at the polls gay nightclub in orlando, florida. family members of victims of the orlando and sandy hook elementary shootings and transgender activists and

members of the health care community spoke, and the event included musical performances. national action network, the brady campaign to end gun violence and the matthew shepard foundation were among the rally organizers. [cheers and applause] >> i'm going to try like hell not to cry. i want to thank everyone for coming, for all your support as we really tried to do the impossible the last seven weeks since orlando. we are here. gives us a round of applause because we actually did it. [cheers and applause] thank the number one question were ask is why are we here? it's 2016. i want you to stop being proud of yourself and those register showing up and ask yourself why the hell you still have to do it. why? because we become complacent as a society.

we've agreed to swap the names of the victims out every few weeks that followed cnn and gap and demand better for children but it isn't working, folks. that is a. tell me why the hell you are still here. i'll tell you why because you allow yourself to believe you're not strong enough to win this fight. i'll donate my money i don't trust that someone else is going to make things change. how's that been working so far? it isn't working there i know i will upset many people with his speech and my message today, and for those who get upset, i say good. i woke you up. get upset because your complacency is why we are dying. we have not lost is that because the other eight that because the other eight or they can lobby or stronger. we have not won this fight is far because we can't get her egos and our asses out of our own way. that changes today. [cheers and