primary care initiative, and to keep others. we will be issuing a report earlier in the fall that lays out with those barriers are. next year we will issue recommendations. thank you very much. spent great, thank you. so let's turn this over now to dr. boling. >> can you hear me? how about now? perfect. yes, thanks everybody for inviting me here. i'm going to take you through my journey, which begin at virginia college university come when i joined the faculty in 1984 after traditional training in internal medicine and primary care, and i thought i pretty much have things figured out, the clinics, the hospital is hosting a great job, safety net hospital.

you can see the words that are just the ones of old and sick a couple of years ago reflecting the emphasis on the are pleased that i started making house calls. that was the thing that was given to do as my first job other than seeing patients in clinic. as i did not all of a sudden things get turned upside down because i found out that the patients i was sitting at home were really not able to access health care in the regular way, that the patients were able to come to clinic could do. they were having a terrible experience of care and landing of an emergency department in the hospital unnecessarily. it was obvious to me at the point that this approach would be a better approach. my journey since then has been to figure out how to make it happen. as you can imagine, these patients having difficulty getting out of the house,, difficulty making a pointless, transportation, them issues and so on, this continues care and in the care that was rendered in hospitals often didn't translate back into the home and the

home-based care plans were laid out in the hospital often times report aligns with what the patients really needed. i'm sure not to leave anything that isn't obvious common sense. the report interaction between the office-based medical professionals and home health agencies. ultimatelyagencies. all the money the patients and their families were basically desperate for help. as the results are bouncing in and out of the hospital. is the picture of a housewife could make house calls. the restaurant internet pictures but they're not the actual patient with actual stay will but we would tell these patients to come back in three for additional follow-up. obviously, impossible, stretcher down those stairs and that sort of thing. we've heard today from of the panel is how important it is to contemplate in a care plan that provides for both integration of social support and medical care.

of social support are partially supported now. not sufficiently well in all cases but the medical care component typically is missing we are looking to add that back in. so now i'll talk to all but about the house calls program mechanics. we are going to take patients who are too sick to go to clinic and take care of them at home. we are going to look them over thoroughly at home in a comprehensive way, then we'll see them as often as they need to be seen. our team will go out there o on the same day basis of have an urgent problem, on a scheduled basis otherwise. as we go into the we will see what's really wrong and what needs to be addressed if someone said the only two medication reconciliation is done at the kitchen table. you can call people up and ask them if they're taking their medicines that can take you to the kitchen and you see a pill bottles half filled, some duplicative, you really haven't done reconciliation. these are the things that happen at the same time, you get a

picture for the environmental safety issues and the real needs are. and you also induce a supportive therapeutic relationship which is unique really in pretty much every environment. that doctor-patient relationship and no is completely different. in order to do this while i found out after couple of years of doing it by myself, you have to have a team. i'm going to shoot a lot of evidence to tell you about the team but i'm going to say that chunk of a team working with you. social worker, triage nurse, of the people to support the effort. and now as we move forward into an era where we're looking for evidence-based models of care you need somebody to analyze and track your data and your outcomes to make sure you're delivering the goods. there is a core tenet at the same which includes the patient and the family, and all the other usual cast of characters around the edge. we talked about the 550 calculations and targeting the

sickest most needy population. so in the world where i live, there are ugly 2 million patients in the country qualify for independent at home, probably three or four who are chronically ill and limited in their ability to get out of the house, that they should probably receive most of the care in the residential setting. there's the others were short-term in a similar situation. my friends and i had been working at this for a couple of decades trying to figure how to do this in fee-for-service. we've worked hard and getting the fee-for-service and burst that raise as much as we could. at that point we still found the teen was not adequately supported. we were looking for a way to construct a mechanism using shared savings as a way of paying for the team-based approach that we felt was most appropriate for these patients. we said it's going to be voluntary participation. will not take away people's health insurance. this would make it popular for people to sign up.

they would have to agree to have their data analyzed and then we would target very sick people. the criteria for that were hospitalization within the last 12 months, subsequent use of medicare services which reduce functional measures, to anwar sues health problems, and our patients are more like five or six serious health problems, and in the demo its 60%. the house calls team use of electronic health record and a program says at least 200 capacity of each local site. those with the criteria. then we wer want to make sure te beneficiaries were going to be protected so we put in requirements for quality measures and guaranteed minimum savings which was important to getting the bill passed through congress. finally, the ineffective programs would be either remediated or dropped, so we wouldn't have people in this

business who didn't belong. we have very strong congressional support, so ed markey and ron wyden with the original introduced a bill, as you can see, we passed legislation that was concurrent with the aca to modify medicare to start this demo at 19 sites around the country. the demo involved the sights of a right of different types but you can see listed the variety as well. we put together a collaborative so we started working together to standardize the process of care, to learn from each other since that everybody was at the same level of proficiency from the beginning. here are the results from the first year as published by cms, showing it was very popular last summer to hear this news, 25000000% across the -- the were enrolled at that point, $3000 per beneficiary was the estimate. is to the programs participating had enough savings to the state and the shared savings

component, and all of the programs improved on at least three of the six core quality measures. seven sites met all six. these are some of the taken for the cms website so we're talking at least in the program i'm working in kind of around $1000 per month per patient in terms of medicare savings was the estimate, or 12% total cost reduction. this led to extinction of the demo by two years, a bill introduced by representative burgess and passed unanimously. and then this summer affecting your savings, ottawa 35 and over 10 years by providing better care to patients who are very functional limited, very surgical ago, very expensive and sort of disenfranchised from health care without this model of care. work is ongoing on a very important aspect which is to calibrate the shared savings

mall because it is important to provide sufficient incentives for these programs with small local programs to grow and thrive in an apartment which is rapidly changing. i will tell you from ever looked around and most of the other organizations that are doing health care for chronically held beneficiaries have not incorporated the housecall concept nearly as much as i would think logically they would do, given the extent of the need in what we've commissioned i think at this point as the effectiveness of the model. i will stop there. thank you. >> so we're going to turn now to the q&a section of a program. again, please feel free to come to the mics in our room. you also have a green card in your folder if you would prefer to write a question. our staff will be circulating around the room to collect your cards and they will bring your questions up to us. again, if you're watching live on c-span were following on twitter, you can tweak your

questions to us at #hnhc. we already have a question of you at the mic but if you would kindly introduce yourself. >> tony hausner, formerly with c. mr. quigley issues i encountered there was a lack of arrangements across the post-acute care setting. when a patient was released from hospital, there was no coordination between the nursing home, rehab center, home health and other forms of post-acute care to the there is nobody making the decision as to where the best place should be for the patient, where the integration of the services coordination between the different programs. that struck me as a great deal of fragmentation but i know there are some of the models you talked about today address that

to some extent, but not a major issue that i don't know that's been adequately addressed. >> i think you are in touch on a major issue and importance of improving transitions in care that involve adding information flow across the studies that you've identified. it involves working with patients. dr. boling talked about having a follow-up appointment with primary care physician within a certain period of time. that is important or of the models that are being tried are using personnel from the hospital setting, whether it's a nurses, nurse practitioners or specialists to actually fall for patients post discharge. but i think we've got a long way to go to really improve those transitions and care. i would also importantly are having quality metrics that look at things like we

hospitalization rates are discharges to home versus discharge to a long state nursing facility. important problem, a lot of pieces have had to make that work well. >> thank you. >> let's move to this micropho microphone. >> i'm a primary care physician, also an attorney and have spent some time represented whistleblowers who allege medicare and medicaid fraud. you haven't talked about nonprofit versus profit. i assume that means you are assuming everything is for profit. out in the field you see a big difference between the visiting nurses association which is nonprofit and the way health care is led by private for-profit or decisions. the home care is directed towards the people who need it in the broad category, the people who need it least.

so the difference between costs and reimbursement is greatest. it's more profitable to treat people who are sick. and you have a say anything about developing not in profit committee service which be affordable to people in different lincoln medicare, medicaid they programs that are nonprofit. this all seems to be in a business setting and i think, well, no has said profit nonprofit. >> when i say, when i think about our recommendation and we're looking at contracts between the states, the federal government, me the plans of providers, there's no expectation on our part that they would all be for profit. in fact, i think one of the largest providers of care for dual eligible individuals are nonprofit plans and nonprofit providers when you think about the community health centers, about a lot of the hospital

systems that are central to care for low income populations. certainly in a way were trying to restructure reimbursement. we're hoping that this will encourage providers to contract with local community-based providers who have experience in providing services to these populations. >> if i could just add today. i think you're getting at a key issue but it's one thing to say in savings or giving or plans financial incentive to take accountability for the full range, but how well do they perform? we know that there is a difference by nonprofit, for-profit ownership. but we don't seem to have a policy that moves in that direction or to even nonprofit status doesn't mean that they would perform as opposed to just being a subsidiary of the for profit entity. i think the important things other but quality metrics and public performance, and it performance, and that goes beyond the sorts of things we looked at to really getting down experiences good character with

having patient experiences of care and having that information broadly available. >> let me say one more thing quickly. it also changes the treatment of the provider of the finance. the home health aide, for-profit sometimes takes people right off the boat, pace than minimum wage, gives them no benefits, gives them no possibility for advancement or training. when they become disabled, they fire them and get somebody new. a nonprofit is less likely to do that. >> okay, thank you. we have a number of questions here for dr. boling about the independence at home. so i'm going to group them together and give them to you in a package. a lot of them are asking about the savings.

so first, what factors are accounted for most of the savings in the model? and regarding the savings, the evidence that you are have for the savings, are you concerned that the savings in your one is 10 million versus number two, 25 million? so let's start there and then i will follow up with the rest. >> okay, thank you. so the evidence related to the savings is predominately being driven by unnecessary hospitalizations. so hospitalizations that were occurring for ambulatory care sensitive conditions such as diabetes, congestive heart failure where nbc action early on in the course of the post hospital care would result in the patient be able to remain safely at home. and the same with emergency departments, and

re-hospitalizations, post, i think i'm repeating myself. a difference in savings between your one which was reported out at 25 million your queue, report at 10 million come as a subject of an ongoing discussion about the best way to measure the expected cost which is a complicated matter. those of you who are involved in health policy as action where eels may have a better understanding of this but it is very challenging to figure out what the reference standard should be. we think we've learned a lot from the demo at this point that should enable us to do that effectively in the future. >> so regarding information you have in your evidence so far regarding severity, functional status, et cetera, what kind of

information do you have that feeds into your evidence so far? this questioner wants to know how you find eligible participants are your program. do you have any issues finding participants? >> a matter of finding eligible participants is simply a matter of looking around the community and seeing who is having difficulty accessing health care as a result of the been functional evidence or so ago. i think many of you who are losing that some experiences with the known families of individuals whose need to access health care was not easy to meet. you may have to take a day off to go with your mom or your dad to the hospital, find somebody to go with them. how do we find these people in real life? people who were discharged from nursing homes often times are in a recuperative phase, may not get back to level of functional status whether it easily able to transfer themselves or be transported. there's lots of people like

this. it's merely a matter of putting systems in place to identify them. home health agencies know who they are. nursing homes know they are. physicians to who they are because they keep turning up back in the ed and wonder why are they here again. we just saw them last month for the same thing. it's not actually a matter of difficulty find these people. it's a matter of aligning the care design with their needs and referring them to programs which need to be created that will ultimately meet those needs to the goal with independent at home is great about which can be transformed and available to everybody. that's our goal. i will mention that were senators have introduced senate bill 3130 now which is making us wait in the legislative process to tak the independence at the entrance and into a national program. >> let's move to this micropho microphone.

>> national employment law project. thanks. this has been fantastic and i think it's very enlightening and helpful to see such great reforms and proposed delivery models. but i wonder if any of you have loolooked at what i was to be te greatest barrier to their success which is workforce shortages and vacancies. and specifically with the direct care workforce, we could argue that someone who sees an individual or five times a week is going to be the best champion and person to prevent re-hospitalizations and prevent unnecessary complications. so how is to integrate into any of these models, or the larger workforce issues? >> in addition to the project we are working on right now that looks at high-need, high-cost

individuals, a bipartisan policy center look at long-term service reports, financing, long-term services and support. one aspect of that is fighting caregivers and providing appropriate support for caregivers. i will say candidly the leaders for the project are senator daschle, senator frist and alice rivlin and tommy thompson. win with a discussion about these issues it's so difficult. when the question of were trying to find ways to help support family members, and if you look within the existing system of care, could you allow an individual, could you allow a plan, for example, to provide support for a family caregiver? there is the issue of come as you know i'm sure the labor laws that have recently come out with respect to reimbursement. it seems like there are so few easy answers out there and we're really struggling with them and

looking at them to try to strike the appropriate balance by making sure that there is an appropriate number of caregivers. but at the same time that the see of laying out existing care which is a difficult, so much of a long-term services support that are provide our provide out of pocket i family members. the consequence of trying to pay for that and by that out seems almost overwhelming to policymakers. if you have some great suggestions, we would love to hear them. >> i think you suggested this in your question, that what we finally look across the country at some of the successful evidence-based models is how it requires a different kind of team, that, and dr. boling talked about this when he listed the members of the team but it often goes more social work. sometimes like a mine adult or cable at home sometimes require bringing him into the house and

living abroad and putting on bathroom bars. i think part of why we see, when we think about workforce we need to really broaden our perspectives. not that you're suggesting this but we need to broaden the perspective and think beyond just doctors and nurses to the complex care managers and the social workers. community health workers. i think we are still going but i think we're still very much in transition about well, not so much the functions but exactly like what kind of accreditation and how does it work across states? and do we need better training programs, certainly. maybe what we need more of is not necessarily at the position level as much as training of physicians and nurses and p.a.s working these teams that are much bigger and broader that include community pharmacy and

complex care managers. >> your there's lots of intensive ta to kind of get to that new paradigm, both of care but also of delivery and training. >> i'm just going to follow up on that for a minute because it raises another question. you are talking, that was a question about workforce but the kinds of care you are talking about raises a question about nonmedical services which a number of our panelists raised today. we have a need for nonmedical services, and i'd like to ask our panel is to dig into that just a little bit deeper. we talked a little bit about what kind of nonmedical services, housing, medical transfer, nutrition but i'm sure there are others. how much of the current movement of new delivery systems models is helping to find new ways to pay for those nonmedical

services? how far down the road are we in getting there? >> all of those services are important to i tend to focus first and foremost on personal care services, certainly for people who can't take care of themselves. that's the number one issue, that being able to maintain their independence. one of the models i am very excited about is the medicaid community first choice program, which for people to meet the qualification or nursing home placement can qualify for personal care services in the home that actually can even be family members other than the legally responsible guardian for an individual, and kind of a government to one the point that was made earlier, those services are provided through agencies

that the state, for example, certifies, that the people providing the personal care services are trained, qualified to perform that role, as well as providing the labor requirements for, whether it's overtime or other types of labor conditions. community first choice, using an agency model to employ personal care workers to assist individuals who otherwise would qualify for nursing home care. >> and i want to point out that in your packets you have a number of materials on the left side of your packets that lists various models that we are referring to today. so if you like the information about some of these models you can refer to those materials. if you're not in the room with us today you can find them on

our website, www.allhealth.org, and you'll find this both in the packets and on the website but also we tried to pull some of them together with the urls. if you find online you will get the hyperlinks. so you will see some of this, and there are other documents in your pocket to also list some of these models are spent i think a lot of the non-clinical services we're talking about today, this is one of the reasons we started with dual eligible individuals, to go so many of these services are covered under the medicaid program, targeted case management services in particular help get to a lot of these issues and take a lot of these issues. in addition states have the ability provide home and community a service under the medicaid program. bears wavers as well as state plan options that are not currently being used at this point. one of the things we looked at

in our february report was whether to long-term services and supports was a means of streamlined those waivers and state options to make it easier and to encourage more states offer home and community based services. that is through the medicaid program, that addresses low-income populations but, frankly, a very small percentage of individuals who need these types of service are receiving them. this is a time in which states are being asked to expand just a two-tier under the affordable care act and expecting to reach out and provide additional home and community based services but it's a tough thing to do right now. looking at them with a look at the medicare program or whether you look at medicaid, i think it support to address those services. >> question at the mic. >> i'm a registered nurse and a data analyst. i guess my question is for dr. boling your for your program

is it a close program, meaning that no more new participants can be enrolled? also, is it a local program? if not, do you have plans to actually have sites locally in the district and in big d. and the? >> fantastic question. thank you. left last valuable not only in fee-for-service medicare, but also other kinds of finance models where people are assuming

risk for high-risk populations. so there are lots of opportunities, if you contact me i can push you in touch with colleagues and friends. >> hi, i am director birthday -- i have to tell you this is just so exciting. it has been a long concert to these issues seriously and now there's demos and exciting ideas bubbling up everywhere. i think i am up for already today. this is really a very positive set of developments. when we look at the horizon, i want to throw out is very important ideas of how they don't quite make center stage. one is that we are all tools of training. if we lived long enough, seriously disabled, almost one of us are protected against the cost we will run that gave one

of the first patient i picked up was a woman who had a disabling stroke in her 40s and the whole time i was growing a come of the whole time i was going to medical school, she was living in a nursing home. no one here has insurance that covers that. an accident of how you work in your lifetime and how your estate deals with medicaid. we need to have the medicare only reports have been, planning to bring out soon. because we will be medicare only in some of us will be medicaid. the second big idea is that the biggest political force in the one weakness really need is those very frustrated caregivers. we need to mobilize back not just as a service to nation, but as a political force. it's really unlikely that mylan pharmaceuticals full text but to lobby for cheaper medical care

system for hospitals and health care are. but caregivers could be really looking for a balanced approach. though we haven't even talked to make them a political force and get almost everybody here has been, will be or now is a family caregiver and it will be the biggest kind of leveling force among us and if it is as bad as it is now, it cries out for organizing. the first thing and i'd be real interesteintereste d in whether some of your teams are running into a gag is that so much of what people need is really community-based. melinda was mentioning this a moment ago. if your town is that universal design housing for a decade, and you've got places people can let it if they haven't come it only got nursing homes. so much of what makes it possible to live well is actually in the housing good, nutrition workforce development

and is geographically anchored. what could we do if we freed up a dozen communities to really move ahead and show us how good it could leave and how inexpensive. i am sure that if we took the savings from the medicare waste and put an end to the social services in any community in the country we would have that much better. i bet some of your iah teams are running into this because they are geographically anchored. they are going into people's homes. so some are starting to show up. meals on wheels allocations and things like that. convert all of medicare into a community anchor in, but some degree needs to come into a priority setting and some funding to communities can use. if we did those three things as well as the clinical service delivery here, we can build a care system that's adequate to

serve the boomers in the 2030s when we all get sick and frail to gather. it seems like we have about 10 years to do our experimentation and if we don't, we will enhance our ability to walk away. they had 800 people on the wait list for home delivered meals. most of them will die or go to nursing homes before they ever get a meal delivered. why isn't that shocking? people on the waste place for cardiac valve surgery, we would all be up in arms. so work with us a little and tell us if some of those names are coming up in your work. >> things for those comments. you will see what works than this. they are starting to occur. buildings that were intended for

another reason repurposed to provide shelter for older individuals in an affordable price of governmental support would be an example. i was going to speak to the workforce put forward earlier. part of the workforce issue is about money. people need to get paid well may have an opportunity. part of it is being a collective effort where you feel like you are making valuable contribution. it is not just a job. it is a mission for a lot of the best people who work in this field. they do better in the game is someone else who cares about it and who also is engaged in the kind of thing like show and discuss where you're looking to find the right place for a person to reside safely in the community. people don't necessarily like to go in nursing homes. very few people clamor to go in a nursing home. i've been in almost all the nursing home so i have a pretty good feel for that.

people would much rather stay in the community. we are better off if we find ways to empower people to remain in the community come or suffer requires some transformative work. he went thinking this way when the houses were built in the trees related the rest of those things were done. we are going to have to do some changing of the way we've got disorganized obviously. the way you figure out how to do that as you go to break the action is, the community at else. >> so i'm going to turn to the questions raised on twitter. a number of questions that have asked about high-cost children. so just wanted to say at the outset that when we designed this panel, we did have a -- the intention was for it to focus on high-cost medicare beneficiaries

but to those who have been asking to the extent, their applicability or transferability, certainly and this is based on years ago and works that supported around child development and complex care for children. the integration of care is equally important particularly when you're dealing with children. again, both for the physical health, the behavioral health and also on the social survey site. you start turning to policy solutions, it is very different from the conversation we organized and structured for today. so i apologize to those of you who thought we would talk more about children, but we really had intended for this to be a conversation in terms of the palace the solution focusing more on medicare, complex patients covered by the medicare or medicaid program together.

there have been a number of more detailed questions. kerry particularly on your proposal. in particular, one person asked that nine months of medicaid, 112 savings for nine months of medicaid if we could keep them off medicaid for the assignment. do you know if that's savings to the federal government or state, is a combination? i don't know if you and amber have done that analysis. >> me make two points. first of all children i do think i mentioned the medicaid first choice program, obviously a lot of eggs. dealing with children with developmental disabilities. that is a good model to look at the limitations are income eligibility. it is quiet though.

it is that the space the poverty level in order to reach and help more families. but to turn specifically to the savings of delaying nursing home placement. first of all, we pick nine-month because we are involved with this emi health care innovation award for mine did maximizing people with dementia in the early pilots of this intervention with memory care coordinators doing home visits and providing -- trained to provide specific support to family members caring for people and average resold with 9.5 month delay in nursing home placement. we didn't just take this nine-month side of the year and when it be nice to do that where there is actually an innovative

model that has achieved that. let me just go over those numbers again. 112 billion nursing home savings over 14 years. a lot of data savings to the family who are paying it out of pocket. so 35 million of the savings are to medicaid and that split federal and state roughly 25545 and financing between federal and state government. but for medicaid. >> grave. since some of the work being done by karen and her colleagues have pointed out, the importance of protecting medicare beneficiaries from spending down and going into poverty to avail themselves of becoming duels because of lack of home and

community-based services, one of the questions is the bipartisan policy center's work in long-term care insurance as a presented opportunity to address at risk beneficiaries from becoming duels. >> yes, we are looking at a number of different proposals. when our leaders began looking at options for cover in long-term care, they realized very quickly that in the current political and fiscal environment, it's going to be a very difficult team to do. and it's going to take a range of solutions, one of which is private long-term care insurance for those who can afford long-term care insurance. personal savings assert my main provider, a main finance of long-term services and support.

but even for those with really high cost, those that need care in excess of two to three years, i think there's a recommendation, first of all, a recognition that people can't save that much money. it is not possible to set aside savings. if you look at the private long-term care insurance industry, you will see they are writing policies. they wrote policies that were lifetime policies for a long time in many of those companies have had to drop out of the market because they didn't have to return on investment because the economy, we had a stagnation economy and didn't have the reserves to cover all the costs. so i think one of the key things for my february report is our leaders recognize there has to be a role for the federal government can pick it up catastrophic some sort of public

system. they are not covering that population in mr. but the medicaid program are not able to address over the long term. i think through these three programs in the short term those are no we say -- there are easy answers but over the long term once someone is catastrophic care, we have to come up with some sort of solution to address it. >> okay. i would like each of our panelists to get up early practical for a minute. if you could ask -- if you could have a direct mind to congress and the administration, and what three things would you like to ask or what do you think are three things that congress and the administration could do to improve the care of the

high-cost population. what could and would you like to see them do? >> of congress and the administration come a gas. >> i think the most pressing thing that i see right now is what is going on with dual eligible individuals. i worked unmedicated work done dual issues for two decades. and it wasn't until i really started taking down in the weeds on this project that i saw how uncoordinated low income populations and how difficult it is. in sam's state you had dual eligible who are in medicare fee-for-service. they are in medicaid for medicaid covered clinical services. there is one managed care plan. they are separate managed care plan for behavioral health services and get a third managed care plan for long-term services and support. you could have a medicare beneficiary who remained but are

still enrolled in three managed care plans. three cost sharing arrangements, three membership cards, three enrollment periods. so we really need to get serious about integrating care for medicare and medicaid beneficiaries. it is unconscionable that we're asking people to navigate the system today. congress needs to give cms the authority to unify the grievance and appeals process and fully integrated dual plans. there are so many things. i should stop it back. >> okay. three wishes, right? obviously i am going to go with my first passion, which is making the independent administration a national program with a salad shared

savings model that will encourage its growth and be sustainable over time. this will have wide reaching benefits. i will go along with the idea of doing something about the duels that i've been involved in the demo in virginia. i'm involved in planning and response to the evolution which is going to be the next stage of that. and endorse the notion that is enormously complicated work that needs to be resolved. past that, i look at all of the older patients better in my care and they are stunned 50 and 60 year old family members who realized the gap that exists between what is available and funded by medicare and the requirements of the care process for one term support for people who are not eligible for medicaid before they spend down, as joanne says we are all destined to do.

those folks are still in the fringe, if they have enough money left in the bank for some property they were so% stock dividend payable release that will dive in to defend out their money to remain in the medicare fee-for-service program without other benefits. there's really in a very precarious situation wahab unit that i. we really -- it's embarrassing how far we are behind in grappling at the society of level. i don't have the answers, but i thought to my patients and families about this all the time and they are just be sad, so i think we need to fix it. >> well, if i have three things on my wish list, i would say dns of the word to demonstrate the care organization concept.

i think we got where we are today empire from the physician group right this model that was tested for five years and became a forerunner of the acl initiative and i think we need that kind of sustained testing of integrated care organizations to really work through how you structure the financial and then to, how you structure the standards for participation, how you structure the reporting, how you go about developing individualized care plans, but reporting on quality, what is the performance and what do we know about the effect of myth of different models of care that they can adopt. we've heard about independence at home. that's a very important one. i stress others like hospitals. melinda mentioned capable. i've mentioned minded home,

maximizing independence. we need these integrated care organizations of innovative delivery models they really work for this population with cognitive impairment and rate the track record and the performance of five. the current cmi is not structured well to do those kinds of demonstrations. the insurance word may cost additional money with offsetting savings in support for people who are not dual. that is the first theme, a dedicated, at least five-year demonstration effort on the part of cms to test the integrated care organization concept. i agree with dr. boling. we need to focus on an airport. this is not a problem of just the duels and therefore turning to medicare to offer at least

the targeted home care benefit under the medicare program's scope would provide financial relief to those who are hardest hit. you seen the striking numbers in the out-of-pocket costs and the burdens on those families and how much that the them at risk for spending down to the medicaid program. the third thing i've mentioned the medicaid first choice program for those who are familiar with it. there's an additional fixed percentage point federal matching were states that do that. about eight states have now adopted that model. these spread across all states that the eligibility level raised to at least 200% of poverty. these types of services to those who are most at risk. thank you. >> i was remiss in mentioning

that two task forces that have been working in this issue and a health and housing task force housing task force and the beaters for both of those have supported extension and expansion at the independent home. night three ira bank and i'm going to be at a higher level around providing and redesigning and further spreading value-based models because i think part of the reason joe wynn, the reason we are having, that we are able to have this conversation with so much success in so much urgency today is because of this shift in the payment bottles away from beaver surveys, away from volume and toward you. we need to spread those models. we need to learn more about them. we need to improve bad as i said before. not just the organizational

level, but also trickle it down to the front-line providers. that would be one. this i can't wait a lot about today is really increasing the flexibility of organization and payers to cover nonmedical services. there has been work done to show which services are most effective, which are most needed. they similarly tangible proposals, some that have been discussed, some that will be coming on ways that would help to improve outcome and allow people to stay at home and also reduce overall cost of care. it's incredibly important to deliver in person centered care as well as to lower overall expenditures. it is the continued experimentation as terry

mentioned the cmi, but i do think there's a lot of foot -- we know a fair bit about the models that work. we know a fair bit about the attributes those models are, but we still run into problems in terms of sustainability spread in scale. we need to kind of continued to in past and can tame you to experiment and learn from the spread and scale of more multisite demonstrations. >> where the question at the microphone. >> thank you for other participation. the one thing i really feel is critical to address and particularly with these really high tide difficult situations where an educational kind of background may not exist at the

level necessary for guidance and assistance. it's very important that we have to include those strategies to address that need that many times there may not be a family member or a real advocate a to hope that individual understand where they are headed to and how we have to absolutely include data. the real high cost of this really exist in those last days or weeks of that individual's life. thank you. >> i think that's an important point. we have it talked about day care in effect again that medicare does not cover care in the home unless you are in a hostage situation of being six months from prognosis. so improving care i think is

very much part of this. if there is not a family member that can take control at least to provide those kinds of services information and support through a positive care program. ms testimony to that, compared to the 25% of dying people in america who end their lives a home where they preferred as opposed to the hospital is something like 60% of patients who were served by an in-home medical care design. when people have come to grips with those issues of the impermanence that we all share on this planet and have accepted

that their health is not going to allow them to continue living, choose to die in a way that is more peaceful and more consistent with prior values and preferences in mind. that is something that is best sorted out with trusted professional team and family environment where you can discuss those matters privately and with people that you know well. that is how those conversations go bass. we force those conversations now in very awkward ways that these two results different from what i think most people would want. i think there is not a great opportunity there and we do know from our work that i've seen now, that costs tend to increase at the end of life. people dying and not design with the relatively lower cost compared to people dying in the usual care about where they wind up in the hospital with an emergency decision, often times

get into beta, go to the icu, that kind of stuff. i think we have opportunities. >> i would be remiss in not mentioning this is an issue very important. we are not addressing it in either this proposal or our long-term services and support proposal because we are focusing on cost of care and we are trying very deliberately to keep end-of-life care issues separate from the discussion of costs. so we will be addressing that down the road, but not a part of this. >> okay. we have come to the end of our time. we've heard a lot of important discussion today. we've heard that there are promising models, that there are challenges when it comes to scalability, workforce, interoperability of electronic medical records and other areas. we've heard about the imported

them including nonmedical services. so i would like to thank our panel as for a very interesting discussion today. i would like to also thank the commonwealth fund for its partnership in bringing the discussion today. i would like to thank you for being here as well and we will see you next time. thank you. [applause] [inaudible conversations]

[inaudible conversations] [inaudible conversations] ..

just last may, when our democratic colleagues asked us to act and act with urgency, but today they turned down the very money that they argued for last may and decided to gamble with the lives of children like this instead of protecting them. as i said, they absorb their own call to get this done quickly and were asked to protect them from a public health crisis. when i started mr. president, this is a test today to see whether our democratic colleagues care more about babies like this or special interest groups and they failed the test.

as simple as that. >> and they approved what happened in the house, planned parenthood, and organizations organizations were hundreds and hundreds of thousands of women's women go for their care, do you think they will have a rush of business now because women in america today want to make sure they have the ability to not get pregnant. why? because the miskito's ravish these pregnant women. under the logic, they can go to their dr. someplace in las vegas or chicago or lexington kentucky they can say i'm sorry, i didn't get birth control, can you help me?

no, that is what planned parenthood is for. that's the majority of women who need help, that's where they go, planned parenthood. there is not enough money to be provided for that - this thursday, issues that congress will discuss when they return from recess. zika virus, gun violence and the impeachment of irs director. we look forward to the debate and update with washington examiner, correspondent susan riccio. >> the book is called "the brain electric", dramatic high-tech race to merge mind and machines. the author is malcolm gay. mr. gay, what is a bci?

>> it is a brain computer interface. what that generally means, there are many ways of accessing the brain but basically what that means is they take electrodes and place it into the brain or atop the brain and not then follows or records neuropsych know's, action potential which is a small electric signal that sells produce when they are computing with one another. that is then put into an a logarithm and transforms it into some form of action command. perhaps it's moving a cursor from the left to right or moving of robotic arm and it's using computer and algorithm electrodes to read intentions from the brain. >> how long have they been studied and where did they come from? who discovered them?

>> that's controversial but basically people have been using this in the brain for very long time to determine various types how animals in the brain initiate movement. it was a 1999 that researchers that researchers realized they could take that intention in those recordings and they could actually figure out, based on the neural rhythms of the firing pattern that the cells work creating to enact certain movement, they can actually re-create that movement. that early work was done. it was mainly done in mice models and then they moved on to monkeys and eventually into humans. >> what is the practical effect of bci? >> what are the benefits or the medical benefits? >> sure. >> there are several, honestly.

on the one hand, this is a technology that could be extraordinary helpful to quadriplegic people who are locked in or suffer from als disease in that, if you think about it, the way that the body and the mind interacts with the world is really only through muscular action. if i want to communicate anything to you, i have to to move muscle to do that, whether it is move my mouth to speak or a hand to write. >> when you lose that ability, particular for people who are locked in, you lose the ability to communicate in a profound way. what this could do is give a level of freedom and autonomy to people were quadriplegic through software that would be word processing software that allows them to speak or speak with the people that are around them or

even use robotic limbs to feed themselves and do the basic tasks of living. that would be a huge step forward for a lot of people who are quadriplegic. there are other areas as well. this is something that is really exciting research that's being done right now. using this interface to train the brain to reroute its neural pathways to help people that have lost function after a stroke. there are a lot of different medical applications. there are other applications as well back malcolm gaye, this this sounds like medical research. is this being done by medical researchers? >> absolutely. it's being done by neuroscientists, one of the traditional neuroscientists, a

lot of people that i describe in "the brain electric" are neuro- surgeons working with a patient group. most of it is being funded by the military, but the people that are working with the research are often quadriplegic. they are looking at this as a chance to eventually help people in a medical setting. >> how is it that the defense advance research project agency, how did they get involved in this project? >> darfur has been interested in bci for a long time, in various various iterations. sometime the interest is in using smarter more robust more

robust military but this program is using the revolutionary aesthetics program and that was spare headed by a named jeffrey lang. this is really about trying to make whole the soldiers that are coming back from iraq and afghanistan for much of this century who because of advances in body armor were not being, were suffering blows that previously would've been fatal but are now just coming back with amputations. these are young men and women who are in their 20s, sometimes the 30s who have their entire life before them and laying, who studied the brain really had a zeal to say this is a program that will make these people whole because we owe it to them the service they have done for the country. it's really, a lot of the

funding that's coming from the military at this point is really geared toward upper limb prostatic's, so robotic arms that the amputees could use. >> tell us about jeffrey lang. >> he is a little bit of a novelty, not a novelty but a rarity because he comes from the military studying neurology and when he joined the organization, he did two tours of duty while heading up the program. it was during those tours of duty that he recounts that he started seeing people come back with these amputations and like many of the people that i profile in the book, he had this moment where there was a soldier who has come back after

suffering a terrible blow. his spinal cord was intact and this kid was just mortified because he was going to be sent home. they said listen, you have a million-dollar wound. you are going to go back a hero and you are going to heal up and you are going to be fine. you are going to do everything you use to be able to do. the soldier just had this emotional response that said when i go back home, i manage a fast food restaurant but here i'm actually helping people in this process toward democracy. that was very compelling and as the head of this program, they relied on this program to really make them whole. >> who else is working on this

brain computer interface? >> most of the people that i profile, many work with the department of defense or the science foundation, but there are several different funding sources. the department of defense is providing a lot of money at this point, but there are a lot of interest in the private sector as well. at this point there are off-the-shelf eeg headsets that you can purchase to modulate your brain waves to better relax or better concentrate. there is some private investment going on as well. much of the research is being funded by universities or other branches of government and it really does have a broad funding

source, that at this point with the people i profiled in the book, a lot of the funding has come from the defense research agency. >> what is the number? >> i would say it's an excess of $75 million for prosthetics for prosthetics. obama put out the hundred million dollars for the brain initiative in 2013. >> is there a market for this type of technology? >> therein lies the problem really. one of the real difficulties that will come up with and i recount one of the more dramatic parts of the book, the research for this is really exciting and the demonstrations are excited. when you see somebody move a robotic limb or manipulate a computer or interact with the digital world mentally, it's a really exciting demonstration.

the market economics that these people run into again and again, however, as wonderful an idea as it is to provide upper limb prostheses to quadriplegics and amputees, these are really small demographics. there are many people in that market. quadriplegics usually have a fairly short life expectancy and most people that are amputees are amputees due to some sort of vascular disease and have lost all or a portion of a lower limb, not an upper limb. most upper limb loss is due to trauma. we can have this demonstration for this work in a lab by dragging it over the hurdler into the commercial market or creating a product out of this becomes a difficult proposition

to get investors interested because they see how much research and development will have to go into this sort of project and then they realize their return on the investment will be likely small. that's one of the traditional problems that have really kept people from becoming a broader product. one of the areas that i think a lot of researchers are looking at, there privatizing and doing more research is the stroke market. there's a large pool of people. all of the sudden it becomes, you can create the product that will actually give investors a good return. there's a lot of interest in using bci for rehabilitative

purposes for stroke victims. >> what kind of progress has been made in the past 15 years? >> it started out with rats moving a lever up and down, so that's basically 1 degree of freedom, moving up and down. the latest and greatest, andrew schwartz at the university of pittsburgh which i recount in the book was able to endow one of his research assistance with 1 degree of freedom in an upper limb. that meant the research subject was able to feed herself chocolate, at one point she beat me in a game of rock paper scissors so very delicate motor skills. being able to create a fist, create 22 fingers, all in real-time. other people are working with creating digital visions.

they would go into the retina with implants that would allow previously blind people to have something to proximate vision. there are people who are working with memory, trying to craft a bci that would allow alzheimer's patients or patients who suffer dementia to form new memories, so on the one hand we are a long way from a world when these tort of advanced bci's are available to the public, on the other hand we have, light years. >> what is the role that jennifer anderson has played?

>> she is a in unlikely star in this. there was a research done in the '90s that found a neurosurgical technique, but one neurosurgical technique that many surgeons employ is the weight awake craniotomy where the patient is awake during surgery. there's a surgeon in ucla that found when he showed his neurosurgeon patient images of jennifer aniston there would be one neuron that would fire incredibly rapidly when she was shown and then they would show a

picture of halle berry or some other celebrity and the neuron would be completely silent. then they would bring back jennifer aniston and there would go again. people have taken it in many different respects and one is, is this neuron that responsible for understanding -- i should back up and say there were other neurons that were found that fired in similar manners to other people so for halle berry or kobe bryant specifically. people began to wonder, is that this one neuron that is responsible for my ability or one's ability to recognize jennifer aniston? of course i have lots of problems because the minute you say that's the one neuron that's responsible for, if that neuron goes away, you wouldn't you would be able to recognize jennifer aniston.

a lot more research or many other researchers have come to believe that it's more of a network. as you're coming to understand an individual or as it's coming in to your information stream, it's neurons that are responding to specific shapes in the face or specific shades of brown or blue and as each one of these neurons create that beacon of understanding and comprehension, along that neuron change, if each one of those beacons lights up, and it's jennifer aniston, that final beacon will light up. it's it's more as an indicator that all of the previous steps in the neuro- chain have been reached. it's more cognitive neuroscience. when you get into deeper, more

sophisticated bci, in terms of motion, researchers are starting to think about how the brain is thinking about the world symbolically and how the brain is seeing objects and how it is going to interact with those objects specifically. that has much more to do with this network notion of the brain understanding individual objects and its relation to physical relation ship to those objects. >> malcolm gay, what are is some of the technology being used to develop this dci concept? >> on the one hand, some of it is off the shelf, there are computers and most of the labs that are making their own computers that it starts with the electrodes and cables, the

electrodes are implanted in the brain, usually, many electrodes are electro grids so there will be hundreds of micro electrodes that pierce the brain in about 2 millimeters. they are against her next to various neurons. when neuro- signals come off the brain, they have to be digitized to get them into the computer and ample amplified. once they are in the computers, most most are built in the labs of the have specific, not necessarily consumer models. there are a lot of rhythm that various labs will make in those labs -- those a logarithm's will then send whatever the product

is to an output device and sometimes a simple videogame of center out technique, they will be targeted in the center and you're meant to move the cursor to a second target and those are very simple video games that are crafted in the lab. when you get into the robotic arms that i recount in the book, those have actually been created by this effort. many of those technologies simply didn't exist before this effort these are tiny motors, various hydraulic systems to actually move the arm, abilities to cool the arm and things like that. the arm itself, the biggest arm

that they created, they created two and one was built out of existing technology and the one i'm describing was built out of the novo technology and will allow sensory information to be brought back to the brain. it's equipped with sensory feelers as well. on the one hand there's a real garden-variety technology there and the other there is the bleeding of the cutting-edge. >> what is the utah array? >> that is the array that i described earlier. it's about the size of a tictac or a small pill. it looks like a bed of nails. it's a flat surface with 100 micro electrodes together like a bed of nails. that has been placed inside the brain itself, and what that gives researchers come a

previously researchers been using one, two, three individual electrodes that they would implant individually. this array gave them a consistent pattern and importantly, it was something that can actually move with the brain. the brain is a fairly, it's almost like the consistency of a flaw in and it will move inside the brain cage. one of the beauty of the array is that it will move with the brain if the electrode itself is static, if the brain starts to shift slightly, untran, then whatever whatever neuron you are listening to previously is gone so the utah array gives you a certain amount of consistency with the interface. there are more arrays being developed in the lab right now. some workers are working on cubes of electrodes that would

scale up the amount of electrodes in their. >> mr. day, in "the brain electric", you tell jan sherman story. tell us about jan sherman and does she use, for lack of a better term, the thought process to make movements? >> so jan is quite extraordinary in the late 90s, she was living in california and she ran a company where she would host these murder mystery parties and during one of the parties, she was crouching down and realized she simply could not stand up. her legs were not obeying her. this was beginning of a rapid decline of her motor function. within three years she was in a wheelchair. she had two children of time,

was living in california, and would go to various doctors to try to diagnose what the problem was. each of the doctors said this looks like multiple sclerosis but it's not multiple sclerosis. it's something else. turned out she had spinal cerebellar degeneration which is a very rare disease, but it characterized by massive motor neuron delay. she has now lost all movement below the neck. for years, this placed jan in a tremendous depression. at one point she was suicidal. she was person who was raised catholic and always had a strong sense of charity and duty. her cause had always been hunger. she lost her ability to help

people in many respects when she lost her ability to move. if she were to go volunteer somewhere, she would have to have someone volunteer with her. she had tremendous amounts of guilt in terms of the burden that she was on other people and her inability to help other people. to the point where she did at one point become suicidal. when jan learned about this research, she was very quick to undergo a craniotomy and sign up for and be implanted and start working with the andrew schwartz group in the university of pittsburgh. but this has done for her, she is quite clear she is never going to really benefit from this herself. the technology is simply too young, but nevertheless, she has received extraordinarily

spiritual meaning to this. it has given new meaning to her life that she knows now she is helping people in the future that may suffer a similar disease to herself. that is really kind of given her a new sense of purpose and meaning in her life. that is one of the really interesting things about jan and a lot of people that participate in this research. it's not so much that they think they will benefit from it necessarily, but it's something that they do in this very brave and courageous effort to help other people. >> at the same time, she has manipulated a mechanical arm several times. that was done through her

thought processes and the technology embedded. >> that's right. the upside is that she gets to play with them pretty well technology. she worked with the arm for a long time, she also flew a simulated f30. there are two separate ways that people will craft a bci and be able to unlock motion. one is this thing about unrelated thought. first if i wanted the cursor to move from the left to the right, i might think about flexing my elbow. if i wanted to move up and down i might inc. about making a fist. they're completely on connected thoughts but they can create recognizable patterns. that's a good way to create an interface rather quickly. you can't really have spontaneous movement and explore the environment the way we would with our biological mind and body.

the way schwartz worked with jan sherman is to not think about it in those terms but to think about it naturalistically. so instead of thinking i'm going to make a fist to move the arm up you simply think about moving the arm up. one of the extraordinary findings of this research is when people are quadriplegic, the brain is extraordinarily plastic and the motor cortex, which is the highly influential in motor interaction, often times those narrows will be recruited for other activity. nevertheless, when that individual, even though they are motor impaired, thinks about moving there arm or clenching their fist, the motor cortex will spring into action as though they were intact. >> where is the future of this technology going?

>> that's a good question. i think the future will start in the medical field in the rehabilitative realm of stroke, i think from their there's a good opportunity to create proof of principle and show that it actually has a medical benefit. once that medical benefit has been shown, i think other pci's will have an easier time of getting investors on board. i think foothold of stroke and the foothold of some of these will allow more sophisticated bci to come forward in the future. >> he is a writer for the boston globe, here is his book "the brain electric" dramatic high-tech race to merge mind and machines.

>> book tv recently visited capitol hill to ask members of congress what they are reading this summer. >> i just finished a new thriller. my daughter babysits for him in nashville and my kendall had quite a few science fiction books. i've kind of gotten into time travel right now. i'm reading time travel, science science fiction and maybe a few classic, just depends on how much time i get to read. generally it's just on the airplane. >> have you always been a reader ? >> i've always been a reader. science fiction has always been my favorite followed by the political thriller genre. >> does it help when you work here in congress? >> it me unwind. there's a lot of reading to be done but it's all bills and reports and nonfiction so for fun, i'm breaking out a novel.

>> it's always hard to find time to read but i'm looking at two books both dealing with the economy and why certain classes don't seem to be advancing in america like they used to. the other is the scandal in money by george gilbert. i think a lot of your listeners may remember him from a few years ago. it also deals with the degree to which the federal reserve is right now making the wealthier people better off but the policies over the past few years in particular have hurt the average guy. that's why we have the stock market boom and the average guy seems to be making that much more money. we have to get beyond years and come back to an economy in which the average guy income is going

up every year. >> books like that, do they help you with your work here? >> i think they give me more confidence in my argument, more confidence in dismantling some of the welfare states and more confidence in the idea that we have to do something with the federal reserve. >> i always like to read books, whether it's novels or biography that are set in foreign countries in which i'm traveling. this summer i just came back from a trip from falluja. i read tremor of forgery which is a psychological thriller in tunis and then i read out of africa again which is an old favorite and a new one called the boulders which is a story of a london lady of high society who went to live a rather scandalous life after world war i. >> book tv wants to know what you are reading this summer.

to address your answer booktv or you can post it on our facebook page, facebook.com/book tv. >> up next, scholars and activists at the carter library talk about civil and human rights. this was the first in a series of national conversations around the country looking at rights and justice. it was hosted by the national archives. >> thank you, it's great to be here. i'm a northerner, born and raised in new york, my mother was from alabama and georgia and that means i have something called hog training. i wanted to say thank you to the faculty and library here who has

done tremendous work here. let's give them a round of applause. in particular meredith evans and i remember my good friend wilson who was responsible for the first time that i spoke care. we will have to see his family here today. i'm looking forward to the conversation and for you all participating as well and if you have questions, we will get to them at the end. they will come collect them and then you can reach out in your

questions and we will try to answer it. we are very fortunate to have this panel of contributors here. to my left is ms. ryan and she is the policy advisor and worked with former president jimmy carter on a range of issues including human rights violations. she represented the center of negotiations including the international court, the human rights offenders and most recently the establishment of the un human rights council. she has worked closely to organize conversations of strengthening the role of hr within the united nations system

on the end we have teresa williams who has a very existing opening statement of geography. she knows what it's like to be held at gunpoint and be called unprincipled names. she endured many years of emotional, physical and sexual abuse. she did what she had to do to survive on the streets and believes that attitude is everything. it was that believe that helps her turn into opportunities of hope. she has a degree from campbell's university and louise state university and surveillance in

engineering from the united states army. not. [inaudible] here in jeff, we have a panelist who is a doctoral candidate and collar and just randomly because of the way he works, not many years ago at all a very serious. [inaudible]

have gone on to do several things since then. in addition to being a doctoral candidate, she is focusing her studies on african history and recipient of the scholarship program award at oxford. you can see her masters immigration studies. finally we have kurt young who is the assistant professor and chair and he's originally from belize city, he grew up in new jersey in tampa florida has a degree in history.

we have this wonderful distinguished panel and i'd like to jump into it really quickly so you can get to the substance of the conversation. i'd like you to all talk about how you came to have your passion for individual freedom and the concerns that were here to talk about today. >> how about we start with karen >> sure, we wouldn't want to presume. thank you, and to all of you, i don't know if i can can follow that section. it was so beautiful and sweet and just wonderful. i'm lucky to have been here for a very long time. i won't say long because then you will look at me and you will

think i'm very old. i've been here long time and i started as a very enthusiastic volunteer and ended up working on various cases of human rights i understood how important it was that president carter achieved putting human rights ahead of form policy. for today's conversation, i think what i'm feeling the urge to think about and talk about is about the conversation they had on our journey for human rights. civil rights as we understand it is very specific to access to participation in civic life. the human rights was a broader concept. we have to see each other as

human beings and there is a way to enshrine that respect for each other in global warmth, in the ideal human idea that we are all human beings. we have been looking at the rights of women because not only do we have strong women and president carter felt very strongly about it, but this was an area where human beings, half of the environment are actually not viewed as full human beings. even as a country were never able to pass the equal rights amendment. we do not all enjoy the equal protection of law. when we have victims of violence, they're not protected by the law in the same way that men are. we have a situation where women wear their body is commoditized where we want to avoid it in other areas. this is what we began to realize

is that we have to boil it down to specific things like access to voting but act also equal protection of the law. this is what we have been up to since president carter and our ceo and that's putting it front and center. when they talk about their book that he wrote and has been a major part of what were doing, we are delighted that others are on the panel giving attention to that issue as well. >> hello and thank you for having us here. to answer your question, my initial entry into the field of human rights came during a semester studying abroad. i was majoring in international studies and they required that

we travel so i chose synagogue were my father is from. i hadn't been since the '90s when i was quite young so is my first time returning as an adult and we went on to her of islam and it wasn't far distance from where my grandparents lived, maybe ten or 15 minute ride but it was definitely a part i would not have seen if i had not been with the university. from there i was curious and it sparked a series of applications to different fellowship programs for research and i was fortunate to travel and work in the middle east in israel and issues with african refugees, primarily from sudan i've done a few other jobs and fellowships around the world. i was able to see how humans are

generally the problem were talking about human rights. in cases like thailand, many people traffic their young girls from hill tribes. they don't have any paperwork so the not protected by the state and i think you can apply that to pretty much every situation whether it's refugees without paperwork or people living in poverty here in the u.s. or atlanta. atlanta is a huge center for trafficking. we have the north and south of the united states, east and west put together and human trafficking in a global sense comes right through atlanta as you have people from southeast asia brought in through the mexican border with texas and up

through the different highways and byways. once i realized that things abroad were very much an issue here at home, it sparked my interest in this field. >> good afternoon everyone, i will start by saying how wonderful it is to share the stage with doctor cobb. i admire your work. i appreciate the opportunity as well as the other panelists. i appreciate this question. the question gives me an opportunity to venerate my ancestors. your question is an easy question for me because in a sense it chose me and i'm sure you can relate to that. it's really a function of my family, my position here is a function of my family, both in the distance that, i remember you mentioned my birthplace in belize, i remember vividly

coming to the realization that i belong to a family that had a very direct personal connection to one of the most active and respected chapters of the improvement association, the organization that was started. i began to understand that there are all types of interpretation at the core that moved me. i related to that and connected to that. secondly, i was able to connect to and come to where i am now through the application of that type of history and those types of experiences to the community that i'm from. i came of age in new jersey and then in florida.

when i graduated from college and continued with my degrees, the rest of my family remained grounded and connected to the roots of their community. we maintain a connection to the community and became a very active part to address the challenges in those communities. that is in the context of a broader effort to understand and eradicate all of those things that make life difficult for human beings to be human. it's really a part of the fabric and i just can't take credit for it. >> good afternoon it was april 5, 2007 when i saw the

article in local newspaper that discussed selling atlanta's children. here was on my farm, living a very privileged life thinking this is a misprint. we cannot be selling our children. on that newspaper was a picture of the child who is being charged with the active prostitution. she looked ten years old. she was an american child, a citizen of america. she stood there alone being charged with an act, she was charged with a crime that have been committed against her. there was something wrong with that and i didn't know what to do except to get on the phone and call people.

you cannot see an injustice like that and not be called to it. it came from me not from my past but in the times that we were sitting in in 2007. today we are centered around the idea. [inaudible] we work on the safe services, training and education and have come complete circle. it brings them to the point of being recruited and we have done nothing. >> i want to return to the question about human rights. i think this is an open-ended question but i think you all have unique perspective on this. we see, historically, lots of images that you can call to mind and images of slavery where

people are completely unaware of the humanities. i wonder if waste trouble, have we made progress? is it more difficult to convey this message now than in 2016? there appears to be a relic of a different area. we must understand what makes a person a human being. what helps us connect with common individuals? >> think they took up this issue earlier when they talked about the normalization of violence. i think part of the problem is the violence is so prevalent in our culture.

[inaudible] it takes the violence to a certain degree and we have to dehumanize those people. as we said earlier we always think were better than somebody else i'm better than another race or gender et cetera. something has set in to our culture that allows us to do that. we see the bikes although the number of people dying in wars has come down. individual violence is ever present.

this is what i think about, how do we actually face that normalization of violence and what we do about it? i do think it plays a particularly important role. someone told me once that pornography is their abuse in their church community and i thought it's that acceptable comics especially now when it's extremely violent. our children have access to it it -- i think the communities must grapple with this. it's harder to talk about it.

[inaudible] in policy circles is difficult to talk about religion, but i do think that is important. >> your question brings to mind a speech given in 1966 in havana in his speech he made reference to the necessity for movement to advance, it has to change those internal contradictions, so let's expand on that and apply to this national project that we see here in the united states of america. there has been this discussion, conversation about human right but there needs to be a conversation about the

conversation that gets to one of our internal contradictions. i think it came out president carter's comments early on in his interview. we almost have this position of being able to proclaim with pride the value, the exceptionalism that defines this american experience. at the same time, we refused to grapple with the contradictions that defy those proclamations that we make about ourselves. the run so deep it will prevent us from grappling with the problem that your question suggests. >> so when we -- i guess we will get to this in some way, i don't want to spend too much time on it but when we reflect on the experience with the first

african-american president of the united states, there was an opportunity there to have a different kind of discourse but the tendency was to proclaim that we had evidence of a post race society or there was the unleashing of the racial tension that resulted in the dehumanizing of this person was the holder of the most powerful seat in the world. what i would suggest is that part of our difficulty in grappling with that program is how we choose or not choose, president carter made a comment when he mentioned the progress. i would argue one of the biggest forces behind the progress is when we have these conversations about our conversation, when we talk about freedom and injustice and race, whether it's through

civil right movement or other movements, and forces us to move forward. at the same time we need to have a very serious look in the mirror and the serious dialogue and grapple with those contradictions. i think we face those very strong thoughts that we been struggling with from the beginning. >> feel free to respond to these questions. it occurs to me that were trying to grapple with these and other lessons from previous movements that we haven't learned and are

there things that are different that we have novel challenges. i want to hear from the lady who is a former student. [inaudible] we put out a new survey as well. >> i think what everyone is touching on is the process of others and when you remove the sense of identity and say we don't share the same citizenship for this person is not like me because we don't share the same gender or i'm not like that person because they're poor and live over on that side of the track and i don't go over there so i don't see them, it's easy to create this in visibility and i don't think there is anything new about it or anything unique or exception to americans in this process. :

and i think the way to kind of try to bridge that disconnect is have a conversation towards work to empower women and children quite recently. it's difficult. universities have an easier time raising money to build a new stadium than organizations that are really serving. your ashes of what is but. people connect with the idea of seeing their name on the doorway into the water fountains as part of the basketball court, but not with sending money, even across town, let alone overseas to work on things that nobody would want to talk about. they are not pretty issues.