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

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

field because the inmates understand which services will be covered and which ones are not and also the providers of those services understand which services are eligible and to give you examples, we don't pay for umbilical hernias or outies and we don't treat your acne or male pattern baldness and we don't pay for your sex change operation or sexual activities. so those are the kinds of services that are not considered eligible. all other medically necessary services and those are the key words, medically necessary services are provided to the inmates within our custody. this do you mean has becument h by the office of attorney general and the constitutional health care. the second foundation is preventive care. i know you've heard an ounce of prevention is worth a pound of

cure and it is of no benefit to deny preventive services. we follow u.s. task force for preventive services guidelines doing routine health assessments and providing chronic illness krinices with the necessary medications that go with that and on a frequency and fortunately, we have a locked up population and the fact that they miss an a poim, that doesn't happen very much. they get to come when they're supposed to come. we have an active yacht liezation department that does preauthorization with concurrent review and planning. we have an active pharmacy and therapeutics committee. we have a formulary and a co pf pay which is legislatively mandated and it's $5 for those prescriptions that are considered to be non-chronic care and it's prescriptions that the inmates come in and say i

want. i want this. i want that. well, it's a $5 co-pay. thirdly, under pharmacy, we have been fortunate because of our relationship with the medical college of georgia now known as georgia regents to be able to have access to 340 of-b pricing for some of our purchases primarily right now for hiv drugs. we actively manage our network, both of hospitals, physicians, ancillary services and medical kim, physical therapy, occupational and rehab. we have a compassion and reprieve process so that any inmate who has a guesstimate life expectancy of less than 12 months from a terminal or chronic disease can be considered by our board of pardons and paroles which is the clemency entity within georgia to be considered for early release. we have telemedicine and telepsyche which has allowed us to extend provision of medical

services not necessarily on site, but through the telecommunications. we have a modular circular uniity in one of the prisons where we are able to take the prisons to on have that done and we have a forensic unit in one of the hospitals that has 22 beds and the purpose of most of those is so we have found the more services that we can can provide behind the wire rather than sending the inmates out into the community, it is both cost effective, cost efficient and our first goal is to provide public safety and that is the rhymary purpose with that. so we do a good job, i think, in providing and getting very creative and providing more and more services behind the wire. our challenges are again, the grain of the inmate population. all states are experiencing

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

medications and we experience barriers to re-entry which includes transition of medical care to appropriate providers. you can imagine that a lot of providers out in the community are not necessarily opening their doors and welcoming someone who is being released from prison. oftentimes they come with no benefits and no resources to help pay for their services. vocational certification and employment opportunities is also a barrier. in georgia, we have a law that basically says that those who become, quote, certified like a certified nurse assistance cna that can provide services in a nursing home, that certification doesn't hold up once they are released. they are not able to use that and thirdly, the residents' restrictions those for sexual abuse and those confined from a sexual sentencing. they have a thousand-foot yard

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

>> good afternoon, everybody. my name is asher turney, i'm a medical doctor from rural alabama and tennessee. i've been a doc for about ten years, and after hearing some of the discussion earlier from miss bay and row. i just want to say we all can have a family member that can be incarcerated and i want them to get the best medical care. i work with the department of corrections and we try to avoid some of those circumstances that they describe. i don't think it's an overwhelming, across t boehe bo pervasive issue, but there are certain situations that, you know, i work every day to prevent.

so i just want to say, my discussion today will be a little bit wider in scope and it will be on some of the issues that we deal with in corrections, but as i said, i completely empathize with anyone who has had a circumstance like that because that's what i went into medicine to prevent. like i said, i'm a preventive medicine, urgent care specialist and i went to the medical college and our goal was to help the underserved. this group is the underserved. it's the same, vulnerable population that oftentimes that fail health care centers and this is the same population that needs access and it's the same job for me whether i'm behind the walls or not. so, i just wanted to kind of describe our situation in tennessee. i am a vendor partner to the department of corrections. i work with centurion, which is a company that has about 60

years' experience in managed care, also in correctional health care. my parent company centene and mha services provide us opportunities and tools that we can can fulfill the individual state's needs. we provide care to the greater service on the centene sides and as well as behind the bars with centurion. we provide local solutions to some of the most difficult situations our partners face, but we also use evidence-based medicine which is probably something that is a newer term it, but we use evidence-based solutions and leveraging technology and predictive modelling and innovative health models to limit incidents and the severity of disease just of some issues to note. so tennessee, welcome to tennessee, everyone.

we a we are have 21,000 inmates across the state and roughly 11 facilities and roughly 11 facilities and we do have some challenges. each state has its own, unique challenges and obstacles as it relates to the correction of health care and we've worked really hard to improve some of those issues and make them -- make them more manageable. the population as a hole, just in general, the general population has been affected and those same issues mirror in the correctional population oftentimes, sometimes it's magnified like we talked about hepatitis c as an infectious disease or mental health illness. you have a significantly higher rate of mental health illness, excuse me, within corrections than you do outside the walls. and we've tried to to deliver solutions to the tdoc that

improve those concerns. centurion has managed the tennessee contracts since september 2013. we have efficiently decreased the numbermissions to the hospital and e.r. by treating on site by getting in earlier with the model to decrease hospitalizations and trying to set up program before we get to patient before we have an exacerbation that requires an e.r. run. we've also trayed to install what we've done. across the state we've installed -- telehealth, excuse me, and telehealth, just to kind of really quickly refresh is a mechanism by which you can use an internet connection or video and telephone to centrally discuss with a professional on one side and an inmate patient on the other with a nurse and have a facilitated medical visit and it allows you to get to the

patient much sooner because in the past you'd have to transfer outside the walls. we brought that onboard and it also decreases the -- reduces the risk to the public safety of transferring and it saves money standpoint of transportation and security. we've also developed in some new on-site services which are continuing to improve the overall health and well-being and i'll talk a little bit more about that on the next slide. i do want to say this just to kind of tag along to dr. lewis' comment. managed care philosophies are improving health outcomes at least in tennessee. so i wanted to just briefly discuss a few considerings and

this is not an exhaustive state of conditions. mental health disease or illness, excuse me, is pervasive in the correctional population so we have to bring in innovative, multi-disciplinary approaches so mental health, medical, legal, corrections, everyone at the table to ensure that these patients get the care that they need and our patients, oftentimes especially in the female population, they have a history of being a victim to violence and substance abuse and those do make more complicated treatment pathways. as far as unique populations within corrections, i think we all have elderly populations. we take care of them whether you're inside the walls or know, but the difference in corrections is that the elderly population and corrections is physiologicly older than the

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

understand cancer increases in incidence as we age and we're having more patients with cancer and we're trying to treat those humanely and respectfully on site. as far as our -- i'm sorry. as far as our female population, females as a group, they have a higher incidence of mental health disease versus the male counterparts. we have less than 5% of the inmates are female and they have significant mental problems and it's a totally different environment to treat patients and we do try to ibring innovation to their care. say with pregnant patients we provide centering. it's a new concept and it's been evidence based and it shows essentially you work with a group of patients instead of one patient and their experiences can then be exchanged and they learn from the grouping.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

diseases, major chronic diseases, we try really, really hard to coordinate the care with the a poim ppointments at leaste beginning. we give them 30 days of medication to get them started. we try at least six months ahead of time to identify and research what benefits that are available for them with medicare, medicaid veterans and try to get the paperwork started so the resources are in place until they get discharged. >> we're seeing a difference between expansion and non-expansion state and these folks are being able to come out with insurance and the non-expansion states both dr. lewis and dr. turney can speak to the challenges they're having and having providers that are essentially a no-pay patient. >> you want to identify

yourself, please? ? i'm a longtime, life time public health official and in an expansion state and it seems to me that a real lever is consumer education and also with the state contracting because in an expansion state, the state is paying for corrections and the the state is paying for medicaid and so in order to coordinate those benefits, on the hospital side we're looking at accountable care organizations so hospitals are coming out and working with community providers to make the discharge meaningful to avert unnecessary readmigs and we're not doing that and maybe someone on the panel is aware of those innovations with following that individual in a contractual arrangement so there's risk sharing or savings sharing by the corrections officer as well as by the public health rf. i ask anyone on the panel. >> there is an example of that in argon and part of their ccos. they actually have set up a

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

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

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

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

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

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

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

>> this is the last question and maybe the toughest. what do you anticipate the new hepc drug having on correctional health care expenditures? >> the easy answer is bankruptcy. and therefore, what? dr. turney was talking also about trying to deal with very large incidents of hep-c population. are you going to prioritize? are you going to test everybody? are you going to allow the use of civaldi for some subset of those folks and how are you making that decision? >> you want to take it?

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

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

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

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

>> you can see it program again at any time in the c-span video library. go to c-span.org and looking live at the u.s. capitol now, both the house and senate wrapping up work today before departing for their five-week summer recess. the senate earlier today approved by unanimous consent, $25 million in emergency spending to replenish israel's defense system and that money will go to restocking the iron dome defense. the senate passed a measure by unanimous consent and that bill now expected to be taken up by the house later today. the house is in recess now and discussions continue on a revised $694 million bill to address the surge of immigrants at the u.s.-mexico border. they are expected to gavel in this afternoon to debate on that legislation. you can see live coverage of the

house on our companion network, c-span and the senate, of course, on c-span2. >> sunday on book tv's "in depth," presidential candidate ron paul, he has written more than a dozen books on politics and history with the school revolution on america's education system. join the conversation as he takes your calls, emails and tweets live, three hours sunday at noon eastern on c-span2. watch more book tv next week while congress is in recess. book tv in prim time, monday at 8:30 p.m. eastern and thursday through friday, featuring a wide range of topics including the middle east, ed kagd, marijuana and covering book fairs and festivals from across the country, book tv, television for serious readers. >> this weekend, book tv and american history tv take you on a trip across the country for the history and literary life of

various locals recovered during the city's tour including the bellingham washington and the identify the onner industry of olympia. the history of macon's r & b music and the super saber f-100 jet fighter. and hear the voices of the mormon tabernacle choir. sunday afternoon at 2:00 on american history tv on c-span3. now a briefing on the financial health of medicare and social security. treasury secretary jack lew and the members of the social security and m board of trustees outlined the findings of a new report this week in washington. this is about 40 minutes.board outlined the findings of a new report this week in washington. this is about 40 minutes. >> good afternoon and welcome. every year the social security and medicare boards of trustees provide a report to congress on the strength of our

indispensable social insurance purposes and this morning the trustees met to complete the annual financial review. i'd like to thank my fellow trustees, the chief actuaries, steven goss and paul spilanik and their staffs for their hard work. social security and medicare are without a doubt the most successful social programs in our country's history, and millions of americans rely on them for health care and income security. together these programs have helped to drive vast improvements in the quality of american life with social security helping to cut elderly poverty by two-thirds over the last four decades and medicare improving mortality rates for the severely ill by over 20%. as today's reports make absolutely clear, social security and medicare are fundamentally secure and they will remain fundamentally secure in the years ahead. the reports also remind us of something we all understand, we must reform these programs if we want to keep them sound for future generations. the projections in this year's

report for social security are essentially the same as last year and those for medicare have shown improvement. when considered on a combined basis, social security's retirement and disability programs have dedicated funds sufficient to cover benefits for the next 19 years. after that time, as was true last year, it's projected that tax income will be sufficient to finance about three-quarters of scheduled benefits. however, social security's disability program alone has dedicated funds sufficient to cover all scheduled benefits for only two years. as was true last year, beginning in 2016 projected tax income will be sufficient to finance about 80% of scheduled benefits. legislation will be needed to avoid disruptive reductions to benefits payments to a vulnerable population. the outlook for medicare has consistently improved since the passage of the affordable care act, and this year the trustees have reduced the projections for near-term spending growth. the trustees project this year the medicare hospital insurance

trust fund will have resources sufficient to cover benefits until 2030, four additional years than projected in last year's report, and 13 more years than was projected in the last report released prior to the passage of the affordable care act. the trustees' report underscore the importance of making reforms to social security and medicare. as the largest generation in american history enters retirement, the pressure on our social insurance programs is growing, and we must make manageable changes now so that we do not have to make drastic changes later. the president is committed to putting social security and medicare on a stronger footing and he's put forward achievable plans to fix their finances. as he's consistently demonstrated, the president is ready to work with congress to usher in responsible reforms and he's prepared to make tough choices. but the president will not pport any proposal that would hurt americans who depend on these programs today and he will not support any programs that slash benefits for future retirees. in closing, i'd like to remind everyone that this week marks

the 49th anniversary of president lyndon johnson signing medicare into law. at that time johnson declared that this new program would shine a, quote, a light of hope and realization on those fearing the terrible darkness of despair and poverty. for decades now medicare and social security have provided dignity and security to millions of hard-working americans and keeping these programs rock solid is one of our greatest responsibilities. none of this will come through easy fixes. but i'm certain that if policymakers of good will on both sides of the political divide focus on creating serious solutions, we'll get the job done. thank you. >> our work in the health care space is focused on access, quality, and affordability, and the last one of those is our focus for today as we think about the trustees' report. as we prepare to mark that 49th anniversary that secretary lew

just mentioned, we know that medicare is considerably stronger than it was just four years ago. the life of the medicare trust fund has been extended, cost growth is down, the quality of the care our parents and grandparents are receiving is improving, and it's easier for them to afford their prescriptions and obtain important services like flu shots and diabetes tests. the report we're releasing today adds to the evidence on affordability. first, the life of the medicare trust fund has been extended by four years through 2030. last year's report estimated it would be funded only through 2016, and in 2009 that estimate was for 2017. second, the report finds that medicare spending per beneficiary is growing slower than the overall economy. per capita spending grew at an annual rate of 0.8% over the last four years, significantly

lower than the growth per capita gdp of 3.1%. finally, i want to highlight the report's finding that the part b premium growth has slowed dramatically. our preliminary projections suggest that part b premiums will be the same in 2015 at $104.90 that they were in 2014 and 2013. that's a growth rate of 0%. while we need to continue to focus on the long-term health of these trusts, as the secretary mentioned, all of these factors do add up to a stronger medicare, one that means we're better positioned to support our parents and grandparents as they age with security and dignity. thank you very much and with that i'll introduce secretary perez. >> thank you, secretary burwell. good afternoon. this year roughly 1 in 5

americans will receive social security benefits, and for nearly two-thirds of the beneficiaries 65 and older, their benefits will account for more than half of their income. older women because they live longer and earn less on average during their working lives are particularly reliant on social security, and it is important to acknowledge a year ago we celebrated the 50th anniversary of the equal pay act. these gender wage gaps persist. as women continue to earn less over their lifetime than their male counterparts, it also means they have less to save for retirement and receive social -- smaller social security benefits once they've stopped working altogether. putting more people to work is crucial to the health of our social security and medicare trust funds, and we've made huge strides in this area. over the last 52 months we've seen 52 consecutive months of private sector job growth, which is the longest streak on record,

and we've been keeping records since roughly 1940 or so. the first six months of job growth in 2014 were the strongest six months since 1999. we've added roughly 10 million new private sector jobs since early 2010, and this friday we will have the next snapshot of next month's job growth. the unemployment rate has dropped to 6.1%. these are all critical issues that affect the financial health of the trust funds because the financial health of the trust funds is inseparable from the health of the labor market, and the health of the di trust fund is something that is noted in the report and one thing that we're doing at the department of labor is to ensure that people with disabilities have access to the workplace. we are in the middle of implementing a very important regulation relating to section 503 which is designed to increase the number of people with disabilities in the workplace.

we're working closely with employers and with other key stakeholders, and we continue to work closely with my friend and colleague carolyn colvin on strategies to increase the number of workers with disabilities who can punch their ticket again to the workplace and to the middle class because people with disabilities want nothing more than the dignity of work, to live in the economic mainstream, and the feeling of contributing to their communities. they want to pay taxes, and that is why we're working so hard to ensure that we help them do so. so our skills and training agenda, the agenda of job creation, these are critically helpful in strengthening the social security and medicare trust fund because a strong economy means a strong social security and medicare system. with that let me turn to my colleague and friend, carolyn colvin, social security administration. >> thank you, secretary perez. the social security and medicare programs are crucially important for the millions of americans

who receive benefits. roughly 95% of americans are receiving or can expect to receive benefits from the program in the future. as trustees, we are responsible for overseeing and annually reporting on the status of the two programs. the combined social security trust fund reserves are projected to become depleted in 2033 if no legislative changes are made between now and then. at that time continuing income would be sufficient to support 77% of scheduled benefits. this year, the year of combined trust fund reserve depletion is unchanged from last year's report. lawmakers should act soon to address this imbalance in order to gradually phase in necessary changes. this will give workers, employers, and beneficiaries time to adjust to whatever changes are made. the long-range actuarial status shown in this year's report is

slightly less favorable than that shown in the 2013 report. based on the intermediate assumptions, the estimated 75-year long range actuarial deficit for the combined social security trust funds increased from 2.72% of payroll and last year's report to 2.88% of taxable payroll in this year's report. this change in the deficit can be attributed to the change in the starting year from 2013 to 2014 and changes in methods assumption and starting data values. considered alone, the disability insurance or di trust fund reserves are projected to become depleted much sooner than the combined social security funds. this year's report again projects that di reserve depletion will occur in 2016 in the absence of legislative changes. at that point continuing income to the di trust fund would be sufficient to support 81% of scheduled benefits.

the disability program is a vital part of this country's safety net. di is not only of immediate important for the 11 million americans currently receiving benefits and who depend on them to meet everyday needs, it protects all insured working americans who will need to rely on this program to replace their income if they become disabled in the future. we owe these individuals a securely financed program that provides timely payments. at this time let me introduce chuck blahous. thank you. >> i'd like to begin my remarks by thanking secretary lew, secretary burwell, secretary perez, acting commissioner colvin, all of their staffs as well as the many dedicated staff of the offices of the chief actuary of the social security administration and the cms medicare actuaries office.

since i am the sole republican among the six trustees, i sometimes feel i bear a special personal responsibility to vouch for the objectivity and the integrity of the process by which these estimates are produced, and i do so today without reservation. in particular i would like to thank secretary lew's capable staff at the treasury department for managing this process fairly and for skillfully identifying the common ground between the various trustees' perspectives. most of all i want to thank my fellow public trustee, bob reischauer, the opportunity to work with and learn from bob the past four years has been the single best aspect of my experience as a public trustee. what seems to have become a tradition is i will speak about the social security report and bob will take on the medicare report. my best short summary of the social security report is that as has been said earlier, the long-term picture this year looks very similar to last year's report, but the short-term picture has grown more urgent. under our current projections we are but two years from the depletion of the reserves of social security's disability insurance trust fund in the fourth quarter of 2016.

upon the depletion of these reserves, there would only be sufficient revenues to finance 81% of benefit obligations. now, it is certainly true that social security's disability program faces distinct policy challenges, but it's important to understand that the financing challenge facing social security's old age and survivors trust fund is just as severe. in fact, of the two sides of social security, the old age and survivors insurance trust fund actually faces the larger shortfall in both absolute and relative terms. the long range shortfall is equal to 2.55% of the program's tax base in worker taxable wages. whereas on the disability side it's 0.33%. together the combined shortfall or the shortfall in the hypothetical combined trust funds is 2.88% of taxable payroll. so this impending depletion of the di trust fund reserves is primarily a symptom of financial strains that affect the oasi and

di trust funds alike. the primary reason we are hitting the di depletion point first is that the baby boomers moved through their years of peak disability incidents before they move to the retirement rolls. many are in the process of converting from disability to retirement benefits and shifting the financial pressures to the oasi fund. by any objective measure it's getting late in the game to forge a bipartisan compromise to sustain social security's finances. the projected shortfall in the combined trust funds is substantially larger, even relative to our larger economy and tax base today than the one that was closed in 1983. those 1983 amendments were intensely controversial and they came far too close to not happening but it's sobering to consider more severe measures would be needed to achieve success today. the longer action continues to be deferred, the less certain that lawmakers will be able to close the shortfall in a way that preserves the program's historical financing structure and each year we delay, we

reduce the number of birth cohorts to contribute to the solution and we increase the relative sacrifices required of each one. to illuminate this, a couple examples. by 2033, the required payroll tax rate to fund scheduled social security benefits would be 16.6%. that would be an increase of over one-third in workers' social security tax burdens. on the other hand, if we reduced benefits across the board in ap an attempt to avoid tax increases, it would have to be 23%, applied to people already on the benefit rolls. it would no longer be possible to balance finances solely through reductions in benefits even if we eliminated 100% of their benefits. now, the moral of this illustration is a sol lution further delayed a solution that's less likely to occur at least from the perspective of one that preserves the historical financing structure. social security's financing method may not be perfect but it has been accepted by americans

for several decades and as we've all seen in many other instances, it is not a trivial exercise to design a politically sustainable means of financing income support on the scale of social security. so we are imperilling much delay. before i close, let me just say a brief word about the technical changes in this year's projections for those among you who are wonky. we slightly lowered the long term price inflation numbers this year. we made a slight downward reduction in the ratio of estimated taxable earnings relative to total wages. that slightly worsens the picture because revenues for social security are a function of taxable earnings whereas benefits grow in proportion to growth in the total average wage index. but these effects are very small. together they added 0.1 percentage point to the actuarial deficit and this along with the 0.06 percentage point of increase caused by the passing of another year together account for the increase from last year's estimate of 2.72% of

taxable payroll to a deficit of 2.88% of payroll this year. to summarize, our long term outlook for social security has not qualitatively changed. what is changing is we are rapidly running out of time to legislate financial correction before the reserves run out. because disability and old age and survivors insurance are closely linked in terms of their basic benefit structures and because they're being strained by similar factors, lawmakers would do well to act promptly to shore up the finances of social security as a whole. with that i turn it over to my fellow trustee, bob riche hawer. >> good afternoon, and thank you, chuck, for your remarks. i have found it a tremendous pleasure to work with chuck over the last four years, and i also want to extend my appreciation to secretary lew and the other trustees for their contributions to this process and also to the

staffs that have represented them in the deliberations throughout the course of the year. the staffs have shown incredible dedication, commitment, expertise, and collegiality as we have put this together and to the actuaries and their staffs who have been incredibly constructive. a primary responsibility of the public trustees is to assure the public that the financial and actuarial analyses and estimates in the report are objective, that they use the best data and information available, and that they employ the most appropriate assumptions and methodologists. as chuck indicated, both he and i agree that we can provide such assurance to the public without hesitation or caveat. once again, we feel that we participated in an open, robust, vibrant discussion of numerous

issue that is have to be dealt with each year as these reports are put together. let me just say a few words about the content of these reports whose bottom line message as has been said before, differs little from those of recent reports. i add my voice to the chorus that has emphasized that under current law both of these vitally important programs are fiscally unsustainable over the long run and will require legislative intervention to correct. the sooner the policymakers address the challenges, the less disruptive the unavoidable adjustments will be for affected individuals, business, health care providers, and the economy as a whole. similarly, the sooner lawmakers act, the broader will be the array of policy options that they can consider and the greater the opportunity will be to craft solutions that are both balanced and equitable.

since chuck has focused on social security, i'll just say a few words about the medicare report, one of them being quite wonky. the first is that unlike previous reports, medicare part b cost projections in this year's report are not current law projections in that they do not assume that there will be a sharp decline in physician fee scheduled payment rates as called for by the sustainable growth rate mechanism, which lawmakers have waived every year since 2003. instead, the projected baseline, which is the moniker that we have given to the prevalent projections shown in the report, assumes that lawmakers will increase physician payments by 0.6% a year when the current sgr fix runs out in march 2015 and that adjustment will continue through 2023.

the 0.0% increase is the average increase the lawmakers have provided over the decade that proceeds march 2015 when they have waived the sgr rules. this baseline change should make the part b cost projections a bit more useful than they have been in the past when they reflected the effects of sharp reductions in physician fee schedule payments. current law projections with estimates of the i will louis trif -- and the world is more pessimistic are still presented in the report. they're contrasted with the projected baseline of various places and then explained in more detail in appendix c of the report. the second dimension of the medicare report that i'd like to comment on is what reaction lawmakers and the public should have to the improvement in

medicare's financial situation, which a number of my fellow trustees have explained and it's very real. nominal per beneficiary costs has been essentially unchanged for two years and have grown very slowly over the past four years. as has been explained, the part b premium in 2015 is expected to be the same as it is this year and was in the previous year. the estimates for the 75-year hospital insurance actuarial deficit have declined from 1.35% of taxable payroll in the 2012 report to 1.11% of payroll in the 2013 report, and now down to 0.87% of payroll in this year's report. this report as you have heard projects that the h.i. trust fund will be depleted in 2030, hour years later than protected last year and last year's report moved the date from 2024 to

2026. some might be tempted to conclude from these good news trends that medicare may be healing its financial maladies all by itself and that no further action will be needed. that would not be a prudent conclusion to reach. projections of health expenditures both in the public and private sectors are highly uncertain. the projected trust fund depletion date can bounce around a good deal from year to year. while the depletion date has moved six years farther into the future over the course of the last three reports, it's worth remembering that between the 2010 and 2011 report it moved five years in the other direction and a decade ago the projected date of depletion came 11 years closer between the 2002 and 2004 reports. this volatility arises because

base year data are subject to revision and going forward the hi trust fund's balances and part b spending are affected by the strength of the economy, new legislation and administrative policies, technological developments, shifts in beneficiary tastes and behavior, and changes in the efficiency with which health care providers deliver services both to medicare beneficiaries and to the nonelderly, nondisabled population. because of our limited ability to predict their future courses with any precision, each of these introduces uncertainty into the estimates, uncertainty that grows the further out our projection extends. although i count myself among those who is cautiously optimistic that the recent slow down in the growth of per capita health spending will continue, our recent protection indicates medicare spending will grow faster than retirees' incomes

for gdp. i strongly concur with the admonition that is repeated in several places in the report as well as in the all trustees' message that notwithstanding the very encouraging experience of the past few years, further legislation will be needed to address the substantial financial shortfalls faced by part a and the growing burden that rises part b costs will impose on taxpayers and beneficiaries. and the sooner the lawmakers face reality, the better. thank you. >> thank you. i want to again thank all of my colleagues on the trustees for the work to put this together and for our staffs for supporting the effort and with that i think we'll take a few questions from all of you. >> we'll take a few questions if you could please wait for the microphone to get to you and state your name and media affiliation. can we get the first question from you?

>> damien plight at "wall street journal." secretary lew, we had a couple democrats propose changes to the payroll tax allocation to send more money to the disability trust fund so that you guys don't have to do -- as a way to fix it, the solvency. do you support that? >> let me say in the past when we have had a situation like this, the measures taken in the short term at least to deal with it was to do a reallocation of the payroll tax rates to support the disability fund. i think if you look from now until 2016, there is probably no other alternative which could produce the desired results between now and then, so i think it's going to be important for there to be legislation that does reallocate the payroll tax to support the disability fund, and then as we go through the

process of looking more broadly at the reforms needed in oasdi to deal with the longer term questions. i just want to underscore that we do have in our budget a number of provisions that would improve program integrity in the disability program. we're going to continue to push that forward, but those are not going to have the consequence in the next two years sufficient to deal with the projected shortfall. >> other questions? >> thank you. i'm amy goldstein with "the washington post." my question is for secretary burwell. the report essentially attributed the improvement in the h.i. trust fund longevity to two factors. one a virt of features of the aca and, two, just a slow down in particularly inpatient

hospital expenditures. i'm wondering if you can talk about the relative proportions of each in explaining the improvement in the trust fund and what specifically in the aca at this point is making a difference? thank you. >> i think that the -- i think what we see and we've talked about today is one of the biggest piece of news is what is happening on the medicare side. as the report reflects, it's a number of things coming together. in terms of the direct attribution in percentage terms, as we have seen recently when gdp numbers come out and that sort of thing, the question at this point in time of our ability to get it to the level of the question you're asking about, attribution at percentage levels i think is something very difficult to do and we have not done. i think what we do know and what the report reflects is that we believe there are a number of things that are contributing to that and we try and reflect the range of those things. one of those things we do believe is the changes that have occurred in terms of the affordable care act in terms of some of the changes that were made in terms of the way that

cms would implement and do pricing types of things in terms of how they're implementing the law and whether that's the medicare advantage changes or other changes that have occurred. i think what it emphasizes though is that what everyone has said, which is we do need to focus on longer term fixes. we're focused today very much on social security because it's right in front of us. i think we can't ignore we need to do a couple things which is think about how to do the long term resolution and at the same time continue the implementation of changes that have been put in place and consider other changes. i think many of you all probably know that in the current budget before the congress, there are additional changes that would produce additional savings. >> okay. other questions? >> yeah, hi. ricardo alonzo with ap. i'd like to ask the public trustees what's behind the ongoing slowdown in health care

costs and how long do they think that's going to continue? >> lots of things are behind the slowdown and there's, as you know, better than most, there's an active debate going on among experts in this area. how much of it is due to the weak economy, how much of it is due to legislative changes like the affordable care act, how much of it is due to pressures that are being exerted both in the public sector and the private sector that have lowered utilization and dampened the growth of intensity. i think we're probably many years away from being able to allocate these various factors

with any kind of precision. the question also involved how long will this go on. if you look at the report with respect to medicare, we have quite slow growth going out for the next couple of years, and i think that's probably a safe assumption with respect to the private sector as well. the increase in the burden that's being placed on consumers outside of medicare through high deductible plans, through increased restrictions on their choice of providers is certainly dampening spending as well. so i have no definitive answer for you, but maybe chuck will.

>> i think there are four points i would make in reply to your question. first is just the same as bob's. no one knows and there is an active debate going on as to how much of it was the effects of the recession, how much was changes in the health care sector, how much of it is attributable to recent regulation. that's not one the trustees are going to settle. second point is you have to remember that we're dealing with projections of the future, and so there's a great sensitivity to what we project in terms of trend lines going forward. so the amount -- we're projecting a more favorable trend based on data received to date. but overall very little of that is in the past and most of it is a changed projection for the future. some of it is in the books, but the amount that the picture has improved to date is relatively slight. if i'm recalling correctly, i

think we were looking at a trust fund ratio in the h.i. trust fund of 72 at the beginning of the year and last year's report and instead it's 76. it's a little better but not qualitatively better. most of the improvement is in the future rather than in the books to date. we have to be cautious that inferring from a change in projections that the reality is much better. we're looking at a favorable trend to date and we're projecting that going forward. the third point is don't get too hung up on the date of h.i. trust fund insolvency. it's only one piece of medicare and it's less than half of medicare. and the trust fund dynamics balance is different than the social security side. on the social security side we have a relatively large build up in the combined trust funds and then a rather precipitous period of draw down projected in the

laity 2020s and early 2030s, and so b so, but we are starting out a with a shallow balance to begin with. less than one year's worth of reserves in the trust fund. it's going to have a very shallow bam for many years. you can have a very slight nudge either favorably or unfavorably in the projections and it can cause that date to move by several years. so again, it's the nature of the beast with hospital insurance trust fund balances. as bob mentioned, we've had a year recently when it came five years closer and now a year where it moves four years further out. the last point i would make is that simply one has to remember that all along the trustees' methodology has been assuming a rather sur stangs slow down in the rate of national health expend dour growth over the next 75 years. we have been assuming that inevitably has to occur. it's nice it's starting to occur but that doesn't mean reality is going to be that much better than our projection methodologist suggests. it rather means our project

methodology is perhaps being validated as being realistic. we have anticipated for some time a slow down in national health expenditure growth and on top of that we're assuming substantial savings arising from the affordable care act. in the latter years of the projection period we are assuming a vastly decelerated rate of growth in medicare costs. while the more favorable trend is welcome and we hope it continues, we have to remember that we have been assuming for a long time that this was going to play out in a more favorable direction going forward. >> that concludes our press conference. we're going to take about a 15 minute break and we'll reconvene for our technical briefing and that will be attributable to senior administration officials.

and a live look at the white house briefing room this afternoon where shortly president obama will come to make a statement. that is set for about ten minutes from now at 2:35 eastern. you will be able to watch it on c-span. also the house and senate are in session today. the house is in recess right now. members continue working on a border security bill. earlier today they passed legislation allowing the bill to be brought up on the floor. this afternoon at 3:45 eastern the rules committee is expected to meet to craft the rules for debating the bill. general debate and final passage expected sometime today. right now we are taking your phone calls on c-span on the border security bill. your input and comments are welcome. the senate earlier today approved $225 million in emergency spending to help replenish israel's missile defense system. it will go to restock the iron dome defense system. the senate passed the measure by

unanimous consent. that bill also expected to be taken up by the house later today. you can see the senate live on c-span2. american artifacts on american history tv. this weekend our visit to the national security archives at george washington university reveals declassified documents about vietnam. 50 years ago this week congress passed a resolution giving president johnson broad powers to wage war in southeast asia. sunday at 6:00 and 10:00 p.m. eastern and watch more american history tv next week. while congress is in recess, american history tv will be in prime time monday through friday at 8:00 p.m. american history tv on c-span3. author sylvia dukes morris is our guest on this week's q & a. >> he was so beautiful and so smart and also so witty, she was just always irresistible to men.

i never saw even in old age, i gave her 80th birthday party and richard cohen, the washington columnist was at this party, and they sat together after dinner having coffee, and at one point she began to stroke his beard and afterwards he said, heavens, he said i have never met an 80-year-old before that i wanted to leap into bed with. she had this vampish quality, a seductive quality, her entire life. >> sylvia dukes morris on the life and clear of claire booth louis and sharing about their personal relationship. sunday night at 8:00 eastern and pacific. yesterday a house subcommittee looked at marijuana use, its legalization in some states, and its relation to transportation safety. witnesses included federal transportation officials including the acting chair of the national transportation safety board and a representative of the center for substantial abuse prevention who heads its workplace programs

division. this hearing of the house oversight and government reform subcommittee on government prices chaired by florida congressman john mica. >> good morning. i'd like to welcome everyone to the committee on government oversight and reform and our subcommittee hearing this morning. this is the subcommittee on government operations, and welcome my ranking member, mr. conley, and others who may join us. the title of today's hearing is planes, trains, and automobiles, operating while stoned. and this, i believe, is our fifth hearing on the subject of the impact of changing laws on the increasing use of marijuana in our society, and our subcommittee in particular has

jurisdiction, and part of our charter is the difference between federal and state laws and the relationships, a whole host of issues that deal with, again, federal/state issues, and certainly in our most recent history there's probably been nothing that has provided a greater difference in say current federal statutes and changing state and local statutes than the marijuana issue. so it's an important matter, and we try to approach it and look at all of the aspects and the impacts. the order of business this morning will be opening statements. i'll start with mine, yield to mr. conley. i see we have mr. fleming.

i don't believe mr. phlegm something a member of the committee, but we'll ask unanimous consent and without objection that he be permitted to participate in today's proceedings, and other members who may join us. right now there are a number of conferences going on around the hill. with that after the opening statements, we'll hear -- i see we have four witnesses. we'll hear from them. we'll withhold questions until we have heard from all of our panelists and get to introduce you and swear you in after the opening statements. so with that let me begin. again, i have an important responsibility to look at changing laws. this subcommittee has, in fact, been investigating federal response to state and local government legalization and change of laws relating to marijuana and examining the

administration's sometimes chaotic and inconsistent policies on marijuana. in fact, most of our proceedings since the beginning of the year have been based on a statement that the president made, and he said that marijuana was not much different than alcohol. i think one of our first hearings what was to bring in the officer drug control policy who differed with the president's statement. we looked at that issue. then we heard from the law enforcement agencies, dea, they disagreed with that statement. then we saw the conflict in colorado and other states, department of justice had issued some guidelines and statements relating to enforcement. we heard, as i recall, from the u.s. attorney from colorado who testified about some of the problems. we heard from dea and other

agencies as we were doing other hearings. the district of columbia changed its law. possession, tampering the down the fine to $25 for one ounce of marijuana and i illustrated by holding up a fake joint. some people thought that was entertaining but it was designed to illustrate you could have 28 of those joints in the district and that would be the results and a $25 fine, and then i held up in the other hand a list of 26 federal agencies that were charged with enforcing conflicting federal law, and it does create a serious dilemma and situation. and, again, i think today is

very important because having chaired transportation, you see the results of the devastation just for example on our highways. probably in the last dozen years we've had a quarter of a million americans slaughtered on the highways. think about that. over a quarter of a million. we've gotten it down, it was down in the 30-some thousand but it was running in the mid -- almost mid 40,000 and that's fatalities, and half of those fatalities are related to people who are impaired through alcohol or drugs, and as we embark on this new era with many more people exposed to what is now still a schedule one narcotic and a more potent as we heard

from some of the scientific folks, we are going to have a lot more people stoned on the highway, and there will be consequences. we do have federal agencies and we'll hear from the department of transportation to see how they're going to deal with both vehicles, both passenger vehicles with commercial vehicles and then also -- i don't know if we could put up some of those charts to see some of the devastation or the photos, aviation is another area. maybe you could put some of those up there. we haven't gotten into commercial, and we'll talk about that, but these are civil aircraft. just keep flipping them. every one of these were involved with people impaired, and the way we find out right now if they were impaired was, in fact, is, in fact, by testing the

corpse, the blood, and this is some of the results we see. the worst train incident that we've had probably in recent memory, keep flipping. let's see -- this is the metrolink. look at that. 25 people killed, and the engineer was impaired with marijuana. and then automobiles, again, this -- i think we have one -- i just showed one on automobiles, but there are thousands of accidents that involve some just marijuana, some a deadly combination of marijuana and other drugs taking lives. so there are consequences to what's being done in our society. today i want to also focus on

the aspect of not only the number of crash victims but also those who are the most vulnerable in this whole process. right now, listen to this, from 1999 to 2010, the number of crash victim was marijuana in their system has jumped from 4% to over 12%. and that's actually as some of this has been kicking in. furthermore, the influence of both alcohol and marijuana they say is now 24 times more likely to cause an accident than a sober person, and i could cite some of these studies . 27% of the seriously injured drivers tested positive for marijuana. now, again, one of my major concerns is the impact on the most vulnerable in our society,

and the trend is most troubling for our young drivers. most recently one eighth grade school senior admitted driving after smoking -- one in eight, i'm sorry, high school seniors admitted to driving after smoking marijuana, and nearly 28% of the high school seniors admit to getting into the car of a driver who had recently used marijuana or other illicit drugs. at night 16% of the drivers under age 21 tested positive for drugs whereas only 7% of the same drivers tested positive for alcohol. as drunk driving fatalities have tripled, a study has found nearly half of the drivers fatally injured in car accidents are under the age of 25. that slaughter i talked about on the highways is impacting no other group as much as our young

people and those particularly our teenagers and those under age 25. as much as 14% of fatal or sustained injury drivers tested positive for thc in 2012. however, we don't have to have data to understand the full scope of the problem. data collection policies are set up by states and generally testing only occurs unfortunately with drivers with fataliti fatalities. drivers who have used marijuana do not exhibit the same intoxication effects as drivers who have used alcohol and traditional field testing is not always effective to identify and remove intoxicated drivers from the road. in fact, we have no standard test for marijuana for drivers. there is no regard te-- standar

test. we don't have federal standards of limits of thc since right now at the federal level any level of thc is illegal. it is a schedule one narcotic, and supposedly zero tolerance but we have no way of testing that. currently there's no roadside breathalyzer for marijuana, but technology is advancing and some countries have started to use a roadside oral test. now, this is one of those testing machines, and this is used actually in europe, and as i understand it, it takes a swab. i was going to have our -- swab the panelists but i thought i wouldn't do that today. but you can take a swab with

this and it can tell you if anyone has used marijuana within four hours. but, again, we have no standard. we have no acceptable test, and we have no way of telling if people are impaired. most of the data we're getting right now is from again fatalities. you have to take -- you either have to take an individual to a hospital for a blood or urine test or, again, the worst situation is to the morgue where we test their blood. in the past ten years marijuana was a factor in nearly 50 aviation accidents. i showed some of the civil aviation. we haven't been begun to think of what can happen in the commercial market as more people are exposed to marijuana. we now have 23 states with

medical use and 2 states who have knocked down most of the barriers, and more people will have, again, exposure to use of marijuana and very little means of testing them. the national transportation safety board has investigate d different accidents and found, again, the use of thc in a number of these accidents, but, again, all of their testing is done after the fact and usually where a fatality is involved. the witnesses today will tell us what, if anything, the federal government is doing to combat drug impaired operation of any transportation mode, and, again,

we have a whole host of modes that the federal government takes responsibility over vehicular simple passenger cars, commercial vehicles, cargo. of course, rail, both passenger and cargo. and, of course, aviation, civil and commercial aviation. we'll hear from christopher hart from the national transportation safety board. jeff michael from the national highway traffic safety administration. patrice kelly from the department of transportation, office of drug and alcohol policy compliance, and mr. ronald flegel of the substance abuse and mental health administration. so i look forward to today's further and continuing

discussions on this issue that has a great impact on all of us and yield now to the ranking member, mr. conley. >> thank you, mr. chairman, and thanks for holding today's hearing to examine the effects of marijuana on the ability to operate planes, trains, and automobiles. i'm going to particularly focus in on the automobile but not to the exclusion of everything else. this hearing addresses an aspect of marijuana policy where i believe there's general agreement over the desired outcome, reducing the ins dents of vehicle accident resultings from driving while under the influence of any drugs. across the political spectrum there's widespread opposition to allowing driving while under the influence of any drug that impairs an individual's ability to operate a vehicle safely. where ditches differences emerge over the most effective policy to achieve this outcome which remains a national challenge. according to the national survey on drug and health use, drug use

and health excuse me, approximately 10.3 people have admitted to driving while under the influence of illicit drugs. it's reported that in 2010 10,228 people were killed in alcohol impaired driving crashes accounting for 31% of all traffic related deaths in the united states. these statistics are alarming and unacceptable. our nation must continue reducing the incidents of any drug impaired driving deaths. a key component to this long-standing effort will be improving our knowledge base through better data and research. with respect to the focus of today's hearing, there's been very limited research actually conducted by the federal government addressing the relationship between marijuana usage and driving safety. reports from the national highway traffic safety administration conclude that

tch, the psychoactive ingredient in marijuana, has dose related impairing effects on driving performance. for example, nhtsa has previously reported, quote, the impairment manifests itself mainly in the ability to maintain a lateral position on the road. but its magnitude is not exceptional in comparison with changes produced by many medicinal drugs and alcohol. yet nhtsa also found maunl intoxication is short lived. peak acute effects following cannabis inhalation are typically achieved 10 to 30 minutes with the effects dissipating quickly after an hour. according to nhtsa, drivers under the influence of marijuana retain insight in their performance and will compensate when they can, for example, by slowing down or increasing effort. as a consequence, thc's adverse effects on driving performance appear relatively small, unquote. meanwhile, the national

transportation safety board held a public forum to discuss the most effective data driven science based actions to reduce accidents resulting from substance impaired driving. in may 2013 it released a safety report entitled reaching zero, actions to eliminate alcohol impaired driving in which it reiterated a represent dation to develop a common standard of practice for drug toxicology testing. technological advances have standardized the uses of a breathalyzer to determine alcohol intoxication. however, states beginning to implement marijuana decriminalization, and there are now 22 of them plus the district of columbia, must act swiftly to address the fact that there really is no legal limit set for driving under the influence of marijuana as there is with alcohol. for instance, field sobriety tests may be accurate and

effective at detecting marijuana impairment. a study of the uk examining the accuracy of field sobriety tests in gauging the amount of marijuana participate pants had consumed concluded there is, quote, a strong correlation between can nis dose received and whether impairment was judged to be present, unquote. of course, anecdote must not substitute for rigorous scientific data. that's why i believe we must support further research in this field to inform the development of effective public safety policies regulating marijuana. and my friend dr. fleming and i had a discussion at one of our hearings on this very matter and i think we agree that that has to be the basis for moving forward. it's got to be based in science, and we need more of it. my concerns over the utter ineffectiveness of our nation's existing federal policy of absolute marijuana prohibition is no more of an endorsement of its recreational purposes use than opposing prohibition of

alcohol is an endorse am for drunk driving. our nation proved with respect to policies regulating the use of other potentially harmful substances that discouraging the inappropriate use of drugs need not and perhaps should not involve total prohibition and criminalization. i have long believed that the federal government governs best when it listens and learns from our states which are the laboratories of democracy. right now those states are undergoing is great experiment with respect to the subject, and we need to learn from their experience and hopefully emulate them in regulations and policies in the future that address both use -- appropriate use, medicinal purposes, and, of course, the issue of criminalization. thank you, mr. chairman. >> thank the gentleman and i recognize now mr. fleming if he had an opening comment. >> thank you, mr. chairman. i would like to thank chairman mica and the other members of the government operations subcommittee for allowing me to

participate in today's hearing. i would also like to thank the chairman for holding this series of hearings that are so vitally important. you know, it took us of alcohol in our culture and it took a new organization, then the organization, mothers against drunk driving, to recognize that we were losing americans wholesale by the tens of thousands, as a result of driving under the influence of alcohol. it took us approximately 400 years to figure out that tobacco was similarly killing tens of thousands of americans every year. in fact, as early as -- or as recently as the early 1960s, there were commercials in which doctors were actually recommending certain types of cigarettes saying that it was good for your throat. i worry that we're not, in fact,

in the same situation in this case when it comes to marijuana. drunk driving is a serious problem according to the statistics compiled by the 2012 national survey on drug use and health. about 10.3 million people, 12 and over, reported driving while under the influence of an illegal drug. marijuana's active ingredient thc is the most common drug found in drivers in crash victims alike. studies indicate that between 4% to 14% of drivers involved in accidents, fatal or otherwise, had thc in their system. marijuana decreases a driver's response time, awareness and perception of time and speed, all of which are necessary tor safe driving. another concern is the combination of drugs and alcohol. you see, whenever you hear that you also hear that marijuana is

inocuous to begin with and number two, it's either or. either someone smokes marijuana or drunks alcohol. it's not the way it works. individuals who are driving under the influence of marijuana will have little inhibitions for drinking beer and alcohol and other substances as well. smoking a joint behind the wheel or whatever it takes to feel good. the rocky mountain high intensity drug trafficking area which works closely with the white house's national drug control strategy is collecting data on the impact of colorado's legalization of marijuana. an august 2013 report indicated that in 2006, colorado drivers testing positive for marijuana were involved in 28% of fatal drug-related vehicle crashes. that number increased to 56% by 2011. and understand that in states that are decriminalizing and

legalizing marijuana and certainly we know from nida who has done some work on this, that as marijuana is destigmatized, as a threat to use is reduced, that use goes up. it finds its way into homes and to candy and to cookies and baked goods. and once it gets there, it finds its way into the brains of teens. we know from statistics that marijuana has a 9% addiction rate among adults. but those who start as teens, that rate doubles to 1 in 6. so it's very important what's happening in these states who are legalizing and even decriminalizing or medicinalizing marijuana. this state's rocky mon hidta report on 2012 data is also very alarming. using data from the national

highway safety administration fatality analysis reporting system, fares, this report due out in october will show that between 2007 and 2012 while colorado's overall traffic fatalities decreased by 15%, over that same time, marijuana related fatalities increased 100%. earlier this year, the university of colorado released a study confirming that colorado drivers are testing positive for marijuana and involved in fatal accidents is on the rise. there is no hard and fast way to determine whether an individual is driving under the influence and there's yet to be established a uniform amount of marijuana which constitutes drug driving. and that is very important because you see in the case of alcohol, when you arrest someone for -- if they've not been in an accident, you just caught them driving under the influence, with so many episodes of that

arrest, that person loses their license. they are taken off the road. that's not happening with marijuana. we don't have a way to do that yet. while driving under the influence is unquestionably a problem, it is also concerning that pot smoking american youth may also have trouble finding a job. this is especially true in transportation arena. the u.s. department of transportation requires mandatory drug testing on pilots, air traffic controllers, railroad employees and commercial drivers. and that can include buses, 18-wheelers. anything that requires a cdl license. these individuals are responsible for numerous lives and is critical that they are and remain drug-free. american will also become more pervasive as states continue to embrace permissible laws an medical marijuana and the recreational use of marijuana in kids and youth will have easier access to a dangerous addictive

drug. and again, back to the medicinal marijuana, there's no reason why we can't use components of marijuana for disease treatment. right now we already have merinol which is a schedule 3. can be used under the monitoring and observation of physician closely monitored the dosage precisely prescribed. and can be done safely like hydrocodoan. it has the same activity and benefit that the plant marijuana has. it is a synthetic thc. we have that already. there is some claim that there are oil extracts of cannabis that can be used to treat certain rare seizures in children. well, it has little or no thc activity. there's no reason why that -- and it's under fast track fda

approval right now. there's no reason why that can't be taken out as well but there's no reason to deschedule or to make legal marijuana which is now schedule one for those purposes. all of those things can be done without reducing the schedule or to legalize marijuana itself. it's no surprise to you, mr. chaurm or to anyone here that i'm opposed to the legalization of marijuana. what is surprising, however, is "the new york times" editorial board is fully supportive of the legalization of marijuana. mr. chairman, i have two response pieces to "the new york times" that i would like to submit for the record. one from the white house office of national drug policy. and another opinion piece by peter wiener published in "the wall street journal" on tuesday. legalization is not the answer. nor is it a prudent decision for america. marijuana remains a dangerous highly addictive drug even

science will tell you that. >> without objection, both of those articles, statements will be made part of the record. there being no further opening statements, members may have seven days to submit opening statements for the record. now let me proceed and recognize our first panel. the first panel consists of christopher a. hart. he's the acting chairman of the national transportation safety board. mr. jeff michael is the associate administrator for research and program development at the national highway traffic safety administration. ms. patrice kelly as acting director for the office of drug and alcohol policy and compliance at the department of transportation. and mr. ron legal is the director for the division of

workplace programs at the center for substance abuse prevention at the substance abuse and mental health administration. i welcome all of our panelists. this is an investigative and oversight subcommittee of congress. we do swear in all of our witnesses. if you'll stand, please. raise your right hand. do you solemnly swear or affirm the testimony you're to give before this subcommittee of congress is the whole truth and nothing but the truth? all of the witnesses, the record will reflect, answered in the affirmative. welcome them again. and i gave misinformation on a statistic, and i didn't realize it until after i said it. and i want to clarify that for the record. i said nearly a quarter of a million people have been killed in the last dozen years an our highway.

it's nearly a half a million people. a half a million people. think about that. and half of those people died. that's the -- nearly a quarter of a million with either alcohol or some substance in their system. i'll get the exact numbers and we'll put them in the record. but i didn't give the rest of the story as paul harvey would say. with that correction for the record, let me first welcome and recognize mr. hart. welcome and you're recognized, sir. >> good morning, chairman mica, ranking member connolley. thank you very much for inviting the ntsb to testify today. the subcommittee's focus an federal marijuana policies affecting transportation is very timely. we have been working extensively for many years to address alcohol use by drivers whyo