suffers a felony conviction and even misdemeanor convictions in many states, they are barred from being able to license practice law. do you believe that those types of barriers, which are collateral consequences, you believe that those should be removed from person's ability to practice law, to get a license? mr. heck? >> i think like any other collateral situation, they have to look at all element. in ohio, someone was convicted and removed. someone convicted of manslaughter has become a lawyer. we have seen where someone is convicted of a theft or fraud

was not given the license to practice law in ohio. so there has to be some type of parody, some type of fairness, if there are sanctions at all. >> so you would be against blanket bans on all who have been convicted being ineligible to receive a license to practice law? >> i don't think blanket bans do any justice. >> all right. mr. jones? >> i think unless there is some public safety that outweighs a person's right to get a law law sense, to pass the bar, unless there is some public benefit that outweighs that person practicing law, then i would say, he should not have that

restriction or any automatic mandatory bans. >> do you know of any initiatives by the aba or state bar association to address that particular issue? either one of you? >> no. i know the project of the collateral consequence of the project did not entail that. it had to do with cataloging and assembling the collateral consequence. which was a monumental task. but the particular issue you are asking about, i don't know of any state or bar tackling that yet. >> thank you. >> i think that just like we see, disproportionate as far as imprisonment is concerned, i think that goes along with that. because so many times the sanctions are attached to a

conviction. i think that once you see the affect it has on the incarceration, imprisonment, you will see the thing on collateral sanction. i think think collateral sanctions, as it relates to employment, as it relates to income and housing, really has an effect in that regard. >> the answer is profoundly. there are studies that show that african-american men who have never been in -- have never had trouble with the law at all, are less likely to get a job than white men with a felony conviction. there are studies that show that african-american men are particular likely to be addressed for drug-related crimes in the community is the same. so the consequences on individuals, families, and

society is profound. >> thank you. >> the gentleman's time is expired. the gentleman from tennessee, mr. cohen. >> thank you, mr. chair. those issues affect my constituents in a major way. second chance opportunities for employment is one of the things i hear most from constituents, somebody had a conviction at some time in the past and they can't get a job. the continuing cycle. but more fundamental is the loss of the right to vote. and i don't know if this has been addressed. just extensively by y'all, but do either of y'all know the history of that particular -- those laws? i was reading about civil death or however it is called. civil death. and that seemed to take away your right to vote and everything else. and being described as barbarous and barbarism by reason and by

morality, et cetera. but we have these laws. does maryland have a law like that, mr. heck. >> maryland? >> yes. >> i have to be honest, i'm not familiar with maryland state. >> which state are you from? >> ohio. >> oh, sorry. they all join the big ten and i'm confused. ohio doesn't have that law? >> right. >> it is mostly southern states. >> what you say, disenfranchisement, the right to vote, which to me is so important, it trumps everything. when you take someone's right to vote away and with the idea of never giving it back, i just think that this should never be. >> mr. jones, are you familiar with my history on these laws? >> i have my own thoughts, but they would be conjecture. i don't know, but i tell you this, the history of

disenfranchisement, but by the time i get back new york this afternoon, i will know. and i'll get that to you. >> i think history goes back to jim crow. i think it was a southern thing. and really, if you look at the states that have those laws and or had that laws, they are generally the same states that justice roberts said no law room, have to have preclearance, because it is a wonderful world, according to justice roberts. it is hard to fathom when you look at the history of discrimination in this country and look at it in boating areas. and those are the same states that put a star let let are on individuals that says thou shall not vote. >> voting in my district, we had an election in may. primary election for county offices. very important. about 10% of the people who are registered, voted. so my theory is, if people who

had convictions in the past were allowed to vote, if they voted by their simple action of voting, they would show they were in the upper 10% of the citizenry. we do in tennessee have a law that i was happy to have sponsored and passed, allows you to get your right to vote restored without going to koirt and having the d.a. and come and bless you, et cetera. but the guy if the house, kind of the knee andre that will character put an amendment on the bill which passed and it says that if you were behind in your child support, you couldn't get your right to vote back. and it is not something that is pretty clearly intended to have a desperate impact. >> there are two states i believe that this task force out to look at, to allow voting while in prison, and i think that's maine and vermont. you can speculate as to why the

two states allow that. but i do believe that maine and vermont, and somebody correct me if it's wrong, those two states allow you to vote while you're in prison. i think that everybody -- that's right. >> is vermont. which is the other state? >> maine. >> maine. >> right. have you to be eating lobster or cheese or something. >> thank you. >> yield the balance of my time. thank you. >> thank you. we still have some time left. so i'll now recognize myself for five minutes. both mr. jones and mr. heck have said that we should repeal all mandatory collateral consequences that apply across the board. now one part of federal law prohibits anyone who has been convicted of a misdemeanor crime of domestic violence from

possessing a firearm, do you believe that congress should repeal this law? >> as far as my position is concerned, again, the aba hasn't taken a position on that. i think we have to look again at the individual involved in the individual crime. so for example, we had cases, domestic violence, which is on my radar screen, and my office. and like child abuse, we take it very seriously. when we have a domestic violence case we have to look is that person an owner of guns our use a gun. i think a broad simply designation of someone who owns a gun should never be able to own a gun again i think has to be looked at very seriously as opposed to using a gun in domestic violence. i have no problem with that person not being allowed to own a gun. >> do you think the current law

which applies to misdemeanors as well as felonies is a good law? >> depending on the circumstance. depending on the circumstance. >> it shouldn't be across the board. >> i don't think it should be across the board. >> mandatory automatic across the board consequences ought to be appealed and we ought to be looking at individual tailoring, the denial of opportunities to individual circumstances and individuals and individual people. this should not be across the board automatic mandatory ca consequences. >> let me ask you another question the time that i have left. when i first was elected to congress my wife and i owned a two family house that was across the street from an elementary school. and we lived in one half of it and i rented out the other half.

say somebody came and applied and was a person who was a recognized minority applied to live in the other half and i found out before leasing it to them that they were registered sex offenders. could my denial of housing because they were registered sex offenders not because they were persons of color or protected minority be a defense in a fair housing complaint? >> not in ohio because they would not be allowed to live there in ohio. you said you lived across the street from a school, correct? >> i did. >> in ohio -- that's been going on and increasing the number of feet as well as number of instances where a convicted sex offender may live. it started out so many feet of a

school, bus stop, so many feet of a daycare, so many feet from where children will be. so that has become more broad. however, in the specific instance that you mentioned, no, because under ohio law they would not be permitted to live there anyway. my office has on the civil side which we also represent have actually ordered people to move and have got eviction notices for people and orders to have them move out because it was close proximity to schools. >> so if i was accused of denying housing under the state or federal fair housing law because i denied them the lease because i lived across the street from the school in ohio i can go to the district attorney and have him represent me against the fair housing complaint? >> under ohio law we cannot

represent an individual interest but we would stand next to you from the standpoint that that convicted sex offender should not live there. >> let me say two things about the sex offender issue. if you look in our report you will see that not only prosecutor attorneys who work in this area but also individuals who are responsible for administering state sex offender registry say the same thing. the first is that anyone is more likely to be abused in that manner by someone within the four walls of their home than they are by someone who is either delivering mail or cutting the grass. you are much more likely to be molested or abused in some way by someone under your roof. secondly, the overwhelming majority of arrests in these types of cases are by first offenders. the number of sexual predators

who are serial offenders is very small. it's not -- so that these prosecutors and these people who run these sexual registries they say the residency restrictions that we placed on these folks are wrong headed and don't make sense and are actually counter productive because you are more likely to have a problem with uncle sam than you are with the guy who is delivering your mail. >> my time is expired. i want to thank all of the witnesses for your testimony and good answers to questions. thank the members for participating. does anybody wish to put printed material into the record? gentleman from alabama? mic please. >> i'm sorry. i asked permission to submit testimony in the record for mr. jesse will on behalf of justice fellowship which is an

independent prison fellowship ministry which offers his perspective on the challenges of reentering society after he served a sentence for a criminal offense. >> without objection. gentleman from virginia, mr. scott. >> testimony from the robert f. kennedy center for justice and human rights. and reports from the sentencing project, state level estimates of felony disenfranchisement and from report from the sentencing project, lifetime of punishment drug ban on welfare benefits be placed in the record. >> without objection. and if there is no further business to come before the task force without objection the task force stands adjourned. >> thank you.

tonight washington journal's interview with michigan state university president part of our special series on universities in the big ten conference followed by events featuring conservative journalists. we will bring you the future of the republican party. and then the western conservative summit in colorado. plus ben carson speaking earlier this year at the press club. college athletics is the topic of a forum today at the national press club. c-span's live coverage begins at 1:00 p.m. eastern. later in the day a discussion with university officials,

athletic directors and sports reporters about the money being spent on today's college athletic programs. that will be live at 3 p.m. the conversation continues with the discussion on whether or not student athletes should by compensated based on the theory of the employees of the school they play for. be part of c-span's campaign 2014 coverage. follow us on twitter and like us on facebook to get debate schedules, video clips of key moments, c-span is bringing you over 100 senate, house and governor debates. you can share your reactions to what the candidates are saying. the battle for control of congress. stay in touch and engage by following us on twitter at c-span and liking us on facebook at facebook.com/cspan. next, a look at the

challenges of delivering adequate health care to the prison population. former inmates and prison health officials took part in this discussion. this is an hour and 45 minutes. your attention, please. i don't want to interrupt your lunch munching, but i'd like to get us started, if we could. we have a lot of ground to cover and some great people to hear from. i know i'm looking forward to that. my name is ed howard. i'm with the alliance for health reform, and i want to welcome you to this program on behalf of senator rockefeller, senator

blunt, our board of directors. the program concerns the health of people in prisons and other correctional facilities and the health care they need and the health care they receive, which may be the same and may not be the same. if you're concerned about getting proper care to those who need it, then how those behind bars have access to care should be important to you. and if you care about state budgets, you need to care about prison health. states spent about $8 billion on correctional health care in 2011, which was about $1 in six of their entire correctional budget. that level of spending shouldn't be surprising. this is not a healthy population. it includes a lot of folks with chronic conditions, with mental illness, with addiction disorders, and it's getting

older as the population ages. so it's not surprising that states are trying a whole range of different strategies to get a handle on correctional health spending. everything from contracting with third parties to deliver the care to having more services delivered on site, to taking advantage of new health coverage opportunities for inmates. so today we're going to take a look at how well those strategies and some others are working and what kinds of policy changes might be helpful to improve both the quality and the value of the care that this population receives. and as we examine these issues, we're pleased to have as a partner in today's program. later in the program, you'll hear from dr. asher, who's a physician from a tennessee joint

venture that provides correctional health care and in which they're a partner. let me do a little housekeeping before we get started. if you want to tweet, that's how you do it, with the hash tag #prisonhealth. if you need wi-fi in order to tweet or do anything else, the credentials are on the screen. feel free to make use of them. there's a bunch of good material in the packets you received when you came in, including biographical information. there's a materials list and

additional material you can go to for further edification. all of that is on our website, allhealth.org. particularly that one pager you should try online because you can click on those things and you don't have to worry about copying a long url. there's going to be a video recording available of this briefing in a couple of days on our website followed by a transcript a day or two after that. and you can follow along with the slides that the speakers will be using today on that website. if you're watching on c-span, you can find all these materials and the slides on our website. you can follow along if that is what you would like to do. word about questions at the appropriate time, you can ask a question three ways.

there's a green card you can fill out and hold up. there are microphones at either side of the room you can use to ask in your own voice. and you can tweet us a question using the hash tag, and we'll monitor and get that up to the dais. the only other thing i would ask is as we go forward, that you fill out the blue evaluation form that's in your packet so we can improve these programs as we go along and cover subjects and have speakers that would be of the most interest to you. to let's get to the program. our format is a little different than usual. there are going to be two panels, not just one. you'll have a chance to ask questions after each one. first we're going to get an overview of the issue and then turn to a view of these issues from some people who understand them from first-hand experience.

and then a second panel will address concerns about health care and the correctional system from the standpoint of some folks who are charged with delivering that care. so starting with our first panel. i'll introduce them all to keep the continuity of the conversation going. we're going to start with steve rosenberg, who's the president and founder of community oriented correctional health services. is there a pronounceable acronym? >> cochs. >> those of you who watch the redskins tryout understand coaches are important. steve's been working to assure health care access to vulnerable populations for more than 40 years and provides technical assistance to correctional systems toward that end. debra rowe is the executive director of returning citizens united here in d.c. with 20-plus

years experience supporting and advocating for those re-entering from incarceration. she holds a master's degree in human services and spent several years incarcerated herself some years ago. finally, we'll hear from jacqueline craig-bey, who's a supervisor at a domestic violence safe house here in town and an advocate for inmates and former inmates among other vulnerable groups. he's the first paralegal hired by the university of d.c. law school, and before she, quote, turned her life around, unquote, as she phrases it, she spent more than 20 years in prison herself. so we're really looking forward to hearing from you folks, and we'll turn first to steve rosenberg. >> well, thanks, ed. thank you, all. welcome for joining us. i'm really appreciative to have the opportunity to talk about this relationship between public health and public safety because they're so closely tied. as ed mentioned, i'm president of cochs.

our goal is to break down the barriers and build connectivity between our public health and public safety systems. before proceeding, i just want to make a quick distinction between jails and prisons to make sure everybody understands what we're talking about. jails are county or city-based places where folks are held prior to trial or for being sentenced to a misdemeanor usually less than one year. prisons are operated by state or federal governments, and folks go there for a longer sentence. with the data you have in front of you, shows the point in time snapshot of who's in jail and who's in prison, but i'd like to turn your attention to the data below that, which is that more than 11 million folks annually circulate through our nation's jails. those folks are there for a very brief time, and 4% of them, only 4% of them end up in state prison.

96% are released directly from jail back into the community. so when we look who's cycling in and out of jails, what we see are these are our nation's most marginalized folks. they're largely young, largely nonwhite, largely poor, and suffering from diseases way in proportion to it the rest of the population. let me just give you some data you can see that. these are the rates of hepatitis for justice-involved individuals compared to nonjustice-involved individuals. and you can see as we get older down the age spectrum, the gap widens largely. this is the data on hiv compared to justice-involved individuals compared to nonjustice-involved individuals. this is the data on substance use disorder. there was a recent study that was completed. it's known as the adam study, which looked at the incidence of substance abuse disorders.

it found between 60% and 80% of those incarcerated had an illegal drug in the body at the time of the arrest. so we obviously can see that much of our criminal justice system is inherently a public health challenge. folks have substance use disorder. it's that disorder that's having them end up in the correctional system. similarly, folks with serious mental illness -- look at that data. national population compared to local population. and for women in particular, this is a much greater challenge. more than 30% of women who have incarceration or justice-involved have a serious mental illness. obviously what we're depicting to you is this is a challenging population. but what i want to show you are their insurance status. prior to january 1st, 2014, 90% of individuals leaving jail were uninsured. so we make this investment in

stabilizing their health care because we are required to under the supreme court's ruling which said that public jurisdictions have a responsibility under the eighth amendment to not be deliberately indifferent to the citizens that are under their charge. so we make this investment in stabilizing them and then the minute they leave the street, typically we lose that investment. but it's the bottom point i think should be of more concern to all of us. a study showed that of individuals incarcerated who had a chronic disease, 80% of them did not receive treatment for that chronic disease in the year prior to their arrest. so if you have an untreated behavioral health disorder, you're not receiving treatment for that disorder in the community. the likelihood of your ending up exposed to the criminal justice system becomes fairly high. so what do we know about what happens when we treat the

underlying substance use disorder? washington state in 2003 ran a natural science experiment. their data system allows them to organize the jail booking data, medicaid claims data, and mental health utilization data. the state provided $30 million of general funds to its five largest counties for them to go ahead and treat as they saw fit individuals with substance use disorder. and the results were startling. notice this is not completion of substance abuse treatment. this is exposure to substance abuse treatment. the first thing you want to notice is the arrest rate went down by 33%. simply by exposing folks to treatment, the arrest rate went down by a third. for every dollar that the state spent on treating folks with substance use disorder, it saved a hard $1.16 in criminal justice costs. if the cost of victims of crime are included, the savings was $2.87 for every dollar saved.

that's on the justice side. now let's look on the health care side. as you've seen, folks with justice experience have very high morbidity. prior to 2003, their health care costs were increasing at a rate of 5.5% annually. once they were exposed to substance abuse disorder treatment, all of the sudden their costs dropped to 2.2% annually. here in d.c., folks are always talking about bending the cost curve. what you have in front of you is a perfect example of a cost curve that was bent simply by providing access to substance abuse disorder treatment. >> bent out of shape. >> that's right. bent way out of shape. where that leaves us are recommendations for you as policymakers in going forward. i really want to give you four things to consider. one is, these are folks who are not mothers with kids with ear aches who are going to bang on the door of the welfare system say, give me a medicaid card.

a study in 2009 in massachusetts showed while there are only 3% of individuals in the state uninsured, 22% of individuals showing up at publicly funded substance abuse treatment programs whose demographic parallel is exactly that of justice-involved individuals, largely male, largely poor, those folks had an uninsurance rate of 22%. so the very first thing i want to make sure you all understand is that targeted outreach for enrollment will be necessary. this is going to be a complex and difficult population to enroll. and that the use of the medicaid administrative claiming program by public safety entities can facilitate their enrollment. most folks within the public safety world know nothing about the medicaid administrative claiming program, and that is a great opportunity for use for states and localities to bring in resources to enable them to enroll this challenging population, and as you just saw,

enrolling this population will save everyone funds. the second is that we need to understand the relationship between substance use disorders and the criminal justice system and how health care providers both in the corrections and in the community can work together to increase public safety. that's the second take home. the third take home is wanting to talk a little bit about how it's important that we understand that we have an our books going back to the medicaid program this thing called the imd exclusion, or that is people who are patients in an institution of mental disease cannot receive medicaid. the purpose of that goes back to the desire when medicaid was started to not have the state hospitals suddenly become financed by the federal government. well, our science and vocabulary have advanced since then. we now understand things like traumatic brain injury. i want to urge you to give very

careful consideration as policymakers to make sure that statutory folks that are 50 years old that may not be relevant in today's world, that we don't fail to meet this juncture of public health and public safety because we're trapped in old statutory and regulatory language and we figure out how to change that world in order to really facilitate the opportunities. and i guess my last recommendation would be to make sure that we pay attention to how we build bridges. we have these two separate silos. we have a criminal justice silo over here. we have a community health silo over there. these silos have not been very good at talking with one another, at informing one another. i guess the third would be that here in d.c. on a policy level, that we do everything that we can to bridge those gaps and to make sure that folks understand

that public health and public safety are incredibly tertwined. with that, ed, i'll go to the folks to your right. >> terrific. thanks very much, steve. could i just ask you one question? >> sure. >> you were talking about new terms. i'll tell you one new term i would appreciate your defining. that is criminogenic. >> sure. what we now know is we now have identified the causes of behavior that result in people gaving in a criminal justice manner, the people becoming justice involved. those come under the general heading of criminogenic. that means the characteristics that have way more to do with mental health, housing, lifestyle, anger management, they have to do with peer relationships, that there's this whole bevy that we know now how to treat. the challenge has been the regulatory framework in a post-affordable care act world that limits our treatment. i want to make it clear that this is a bipartisan issue.

governor perry, governor deal of georgia, they've been going out and promoting treatment of criminogenic behavior rather than incarceration. what changes is states who have enrolled in the affordable care act is to scale this at a level a state governor cannot necessarily do. >> thank you very much. we'll turn next to debra rowe. >> thank you, ed. all right. good afternoon. during my incarceration at the reformatory in the late 1980s, i witnessed the disheartening maltreatment of who were ill and resided in my dorm. for example, the women who were sick were kept at the very end of the dorm. this was during the time when hiv and a.i.d.s. became prevalent in communities can and several of the women that i am referencing had hiv infections. during that period, i met my colleague here, jacqueline.

you see, we along with a few other sisters were the voice for those women. we raised cane and forced correctional officers to get off of their behind and get them to the infirmary when needed. and we bathed and fed them ourselves. upon release, i was offered a job by the d.c. department of corrections health administration to educate my inmate and re-entry peers about hiv disease. while studying for my job, i read a report from the centers for disease control that stated that 16% of those entering d.c. jail had hiv infection. and i wondered, how did they know that? i began my personal inquiry because i knew that hiv testing was not being offered at that time. i'm going to venture out and say that they were blind testing these inmates, and after advocating for testing in the jail, the correctional medical staff was frantic that they didn't have the resources for the testing, which confirmed my

suspicion about the blind test. i see the same parallel with hepatitis c and that many, many women, some of whom have served ten years or less, who have had blood draws have contracted hep c infections and were unaware of their status until they came home and visited a free community physician's office and learned of their results from a laboratory result there. one inmate who has served 15 years in prison went from lewisberg to cumberland, then to petersburg and then to petersburg camp and had blood draws upon entry to each of those institutions. yet, he did not learn of his hep c diagnosis until he was tested at a community clinic upon his release. according to the center for disease control, the prevalence of hep c infection in prison inmates is substantially higher than that of the u.s. general population.

among prison inmates, 16% to 41% have ever been infected with hep c and 12% to 35% are chronically infected compared to 1.5% in uninstitutionalized u.s. population. it's primarily associated with a history of injection drug use. cdc recommends that correctional facilities ask inmates questions about their risk factors for hc infection during their entry medical evaluations. inmates reporting risk factors should be tested, and those who test positive should receive further medical evaluation to determine if they have chronic infection and/or liver disease. although it's not exclusively considered a sexually transmitted disease, the hep c virus has the potential to be spread through sexual contact. it shouldn't matter that they

are incarcerated. they have the right to know. all of this is happening in the private prisons. in closing, the inmates have reported that their health services are limited, and they're being charged. they have to pay $5 to sign up for a sick call and medications, and you can pay and sign up to see a dentist, for example, and may not see him until the following year. one inmate told me a few days ago that he had an abscess that swelled up to the size of a baseball. after three weeks before he was treated. i'm passionately concerned about those who are 55 and older in the system. this concludes my story, and i'm happy to answer any questions. and i do concur with all of steve rosen burg's recommendations. thank you.

>> thank you very much, debra. and of course, for those of you who haven't been reading health policy stories for the last year or so, hep c at $1,000 a pill has a cure. prison systems and other correctional facilities right now are having to figure out how to deal with the kinds of percentages and the numbers of inmates and residents that debra was talking about. so public health meets -- >> public safety. >> correctional policy. you bet. now we'll turn to jacqueline craig-bey. thank you so much for being here. >> thank you for having me. excuse me. my name is jacqueline craig-bey. i am a former inmate. i have several stories from when i was incarcerated as it relates to the medical in prison.

while i was there, i broke my leg, and it took them approximately a week before they got me to the hospital. i was taken to the infirmary there in the jail, and they put a makeshift cast on. i mean, it was just put on with no padding, no anything. i don't even know if the lady had a license to put this thing on me. when i finally got to the hospital a week later, the doctors over there laughed about it and called one another and come and see this funny thing that was on my foot. the medical facility just didn't a place where inmates should be. nobody there is actually looking to take care of an inmate. it's just a job to them.

they're just there for the paycheck. when i was pregnant, i had a child while i was incarcerated. and after i had my child, you know, women here know that you have to have a six-week checkup after having a child. well, i saw the doctor in the hallway. he just touched my stomach and said, oh, you're fine, and that was my six-week checkup. and these are the type of things that go on in the prison and are not talked about. nobody talks about the people who have hiv, and they're afraid for other people to know that they have hiv, so they don't go to the medical facility to get their medications. they don't want people to know their status. so these are people who are

sitting there with this disease and not being treated. they don't have the staff to talk to these women and men, to let them know it's okay to come to the infirmary or some kind of way to give them this medicine without everybody knowing what the medicine is. because when you go to the line, everybody knows what everybody's taking. so some people don't want to take their medication. and that's a problem. that's a big problem. there should be some kind of way where women or men can get their medication without the world knowing what you're taking. also, i've seen people pass --

die in prison for things that could have been prevented. women were coming down with cancer in connecticut, and it was just crazy. it was so many women at one time coming up with these cancer diagnoses. before they would take them to a facility to be treated, they would sit them there and talk about all these different tests, and had they taken them to a facility to be treated before doing all these different tests and sitting them there waiting around, they could have been treated and would have been fine probably. but instead, they sat there and waited and waited and waited, and these women died in prison. when they got there, nobody said that they had cancer or anything. so they were not tested for these things. but yet, they had these different ailments and nobody in prison cared. nobody cares what goes on with an inmate. they consider us the forgotten, the ones that nobody cares about. so we have to care for one

another. so i would call attorneys and people that i knew in the district and have them fly to connecticut to help one of the sisters or brothers that needed some help, because otherwise we'll sit there and languish in prison with no help at all. and it's just a really sad thing for us to languish away like that. and that's all i have to say today. >> that's quite a lot to have to say. thank you, jacqueline. let me just ask both of you -- you've described some conditions that would result in the issuance of some arrest warrants if they occurred in some other situations. and i wonder what your perception is of the progress that is being made in the

facilities you know about toward addressing some of these shortcomings. >> there is no progress being made. people are still -- jackie was in -- how many years ago in connecticut? >> 2001. >> okay, 2001. women and men are still dying, and family members -- i receive calls from family members that they were just notified that their family member died and they buried them. or they died, and they can't give you any answers. are you going to be able to make accommodations for your loved one or not?

you know, it's just point-blank like that. they're still dying. all of what i just talked about, the young man with the abscess or the people coming home with hepatitis c and not knowing or the people that are in there very ill -- our women -- d.c. gave up the rights to our inmates. we were blessed to be in lauton reformatory during that time. but they closed our local prison. so all of our women are in a medical facility way down in florida. d.c. residents. that's another thing. they're far away from home, and they're sick and they're far away from home. at least if they were in their vicinity -- and they're supposed to be in a 500-mile radius, but they're not. they're all over the country. our inmates are spread all over the country. but it's not just speaking for our d.c. inmates. any inmates. i collaborate with a lot of different states on advocacy for re-entry. but anywhere, the family contact is very important.

it's very important that you're able to have contact with your family, especially if they're ill. just like i said, if you're blind testing people and they don't know, just like cancer, if it's undiagnosed, then -- i mean, look at the people that go to the doctor and they tell you, you have six months to live. but that cancer was in your body longer than that. these these are -- it's like they're just forgotten buzz they're locked up. you know, when they come home, they have what they call the new federal second chance act. because they deserve a second chance. so these long-imposed sentences and then you're not going to take care of them. like i said, you have -- in oklahoma, you have a lot of elderly geriatric people. a man came home 70-something years old. he called my colleague and said -- he's still on parole. they said i got a job. they said i got to get a job.

what is he going to do? that used to be your night watchman or something like that. what is he going to do? all we could do was get him some glasses. he didn't get proper treatment for his vision. for his vision. so my colleague helped him to get glasses. but we couldn't help him find work. but still, why hold somebody to 77 and 85 and they're sick. it's very expensive to take care of them. so, i know that these reforms and they're talking about medicaid and all of that now, but they're going to have to go back and cover a lot of inmates because a lot of our people are suffering in prison. and if you make too much noise about it or your family calls and advocates, you can get put in the hole. you know, and imagine having a

toothache and you're in a cell. because you know you need to pace back and forth. any pain, you got -- you need some type of release. but you're in a cell in agony, in a cell. not in an infirmry. at least in an infirmary, you can lay down and you can -- and you're getting seen or anything. a year to see a dentist, a year. and you're paying for it now. you're paying for it. you work, and if your family's not sending you money, then you work in a detail so you have money for commissary. but now you pay $5 for this. it's taken out of your money. you're paying for your service, but you can't be seen. it's -- no, there's no progress. there is no progress. >> ed? >> steve, please. can i frame that? >> sure. >> i don't disagree with anything debra is saying, but i want to frame it.

traditionally, we send folks out to islands when they need to be incarcerated. devil's island, alcatraz, australia. parts of the united states early on in our history. we've always had this approach that folks who were in the justice system should be isolated and kept separate from folks. in that process of keeping folks separate, the kind of experiences that i'm hearing you and jackie describe are not uncommon. the blessing is we're all in this room, in this very lovely senate chambers today. we're in this room for this very lovely senate chambers today because we have this bipartisan opportunity to change that. and we have this bipartisan opportunity to change that because we recognize that keeping folks isolated on an island does not make sense in the 21st century. and that we have to figure out how we build bridges. and those bridges are partially electronic medical record bridges, which we'll be talking about in the second panel. those bridges are partly thinking differently about how

we do sentencing for nonviolent, nonsexual offenders. but the important thing, i think, is the pony in this. we're sitting here in this beautiful room in the senate today because there are several hundred of you who are recognizing that public health and public safety are intertwined. and managing public safety by keeping folks on an island is not the way that we want to go forward. >> pretty good frame. we are going to stop at this point and ask if you have questions for any of the panelists who are up here. let me remind you you can either fill out a card or go to a microphone so everybody else can hear your question. if you are part of twitterverse, you can use that as a medium to get the question to us as well.

there's another microphone right over here, sir. >> so -- >> i would ask everybody who comes to a microphone to identify themselves and try to keep the question as brief as we can so we can get to the most questions that we can. thank you. >> i'm dr. caroline poplin. i'm a primary care physician. i have a quick comment about disability. i worked for social security disability for a while in baltimore. very often we could not get prison health records. i mean, we had people who weren't in prison who had no records at all. the people who were in prison, we knew they had records, but very often the prisons wouldn't send them and the states wouldn't work terribly hard. that should be something easy, especially with electronic records. >> debra? >> i want to say now, we have in the district made progress in that area. i used to facilitate a federal partner's meeting. it was u.s. parole.

the u.s. parole, the -- and with our medical system here, which is unity health care. that's where all of our community health clinics are. and we sat down and we worked it out where all medical records -- because even when an inmate leaves the prison, they had trouble getting their record. so now all of the records follow them. they all go to unity. they're centrally located in unity. that's one progress we have made in the district. >> and a one-sentence question. does the work that they do in prison, does that count towards medicare -- social security, medicare? >> no, it does not. there is a statutory prohibition -- >> wow. >> -- for medicare paying for any services provided behind bars. there's also a statutory provision that if you're on

parole or probation, you cannot receive a medicare benefit. on the medicaid side, there's something known as the inmate exception, which goes back again to the original finding of medicaid, which states that if you're an inmate of the public institution, as the exact statutory language, then you cannot receive medicaid benefits at all. so again, one of the challenges going back to my comment about islands, and what i'm hearing you say is we need to figure out creatively how we build bridges to those islands. obviously, medical records is a part of it. thinking about bringing standards of care that medicaid brings is another part of it. but at this point, we're all very much in the process of understanding it is not in our benefit to maintain those islands. and then the query becomes, how do we build a bridge? >> thank you. >> if i can just -- i don't know whether this is something that you've had to grapple with, but one of the parts of your question was whether the work that was being done in prison

could be counted as a quarter that would give you credit toward medicare credit coverage eventually. >> and the answer is no. >> no? okay. >> the answer is no. >> hi. >> yes, sir? >> glen field, urban affairs advocate. and a few other civil rights law firms. debra, i heard you mention a 500-mile law. we constantly let this government get away with it. we have a law that's established that any d.c. court offender or d.c. inmate couldn't be moved no more than 500 miles just to keep them with your family members, your loved ones. people in the district of columbia do get locked up, most of the time because they've been traumatized. i'm sure ms. rowe can identify with that. we have racial disparity going on here in the district of columbia.

any inmate -- like 3,500 return back into the city. and 85% goes back within three years. so, you celebrate. am i right, ms. rowe? you celebrate that you made it past three years because it's a resolving door. and it has been set up for that, for the revolving door end of it. i'm just asking steve and the panel, if you can agree with me, in the prison industrial industry, that they make a profit off this revolving door. so when you don't get proper health care, as far as mental health care, when you've been traumatized, post-traumatic stress disorder, you're coming back to prison. and the private industry makes a lot of money. they don't spend that money on health care, mental or physical. if you came into the prison system in the private industry and your pill cost $1,000 or 30 pills cost $600, you're not going to get that medication. you're not going to get the treatment you had in another facility or when you were at

home. because 60% of any profits in the prison system as far as private are concerned is medical. and a lot of people have been suffering. and they're going to suffer more. then they're allowed to come back out on the street. i'll point it out to steve, you know, mostly that we do need -- wouldn't you think we need some advocacy and some monitoring mainly at these private prisons and making sure that their discharge plan starts earlier than eight months. doesn't mean the discharge plan you physically and mentally start getting these people back into health instead of sending them back out on the street, passing on diseases and thinking about new crimes can and things of that nature. because people take drugs because they've been traumatized in these prisons. so it creates a criminal. because they've been

traumatized. they don't know how to deal with these mental health illnesses. they have to supply their habit, and they're coming to get the citizens when they come home because they haven't been treated correctly. so you got worse off than what you were before you went in any system. i'd like the panel to chime in on any and all of that. thank you. >> i'd like to answer that question by framing slightly differently. we have proprietary companies that provide medicaid services through the united states. but those companies are regulated. those companies have performance measures they need to meet contractually. the challenge with the correctional health system is by and large, it's an unregulated industry. and if you have an unregulated industry, then you have the opportunity for both the kind of human suffering that we heard debra and jackie describe, and the opportunity, sir, that i just heard you describe. i think, again, that's partly where being in this room in this building points to something we

don't allow in any other sector of spending $8 billion on health care. do we allow it to be unregulated? do we allow it to operate without standards, without quality assurance, without any of the things that are statutorily required? so we now leave that under our federal system. we leave that up to states and counties to go ahead and regulate or not regulate as they may see fit. so what i'm hearing you describe is an underlying challenge that our federal system has allowed state localities to make their own determinations as to what regulatory or quality assurance framework they're going to put down on correctional health. and in many jurisdictions, that's very nominal. >> okay. we have two folks at a microphone, and we really need to get to our second panel as well. so i would ask you to ask your question and we'll try to get it answered as expeditiously as possible.

>> i just want -- my name is mary tierny. i'm a pediatrician. and i worked in correctional health before. i had the privilege of getting a chipper 1 grant. we did outreach to youngsters who were come out of the juvenile justice system. we got them on medicaid before they were -- or at least at the time they were discharged. we coached parents. we coached the youth. and the two people that really should be given credit is jane adams in kansas who ran the program and the medicaid director who was full force behind this in dr. andy ellison, who at the time was the kansas medicaid director. he was magnificent in getting this. the recidivism rate was dropped by 50%, even in the highest risk youth. i'm sorry. i don't have a question, but i think it's a good model to think

about. >> thanks, mary. >> can i go ahead? >> yes, linda. go right ahead. >> linda flowers, aarp public policy institute. so in my mind -- and thank you for this panel. it's just been tremendous and very insightful. i'm learning a lot. so it sounds like there's this cause shifting going on between the federal government while they're in there not paying for the things that people need, and then they get out -- if they're in a federal prison. then they're in a state responsibility, whether or not there's a medicaid expansion or they become disabled or aged and can get on to medicaid that way. so i'm wondering if you could -- first, there needs to be more data about the amount of money that is not being spent on one end and how that translates into increased spending at the state level once most of these people get out of prison.

which one of your -- i think that could be a powerful tool for states to use to try to leverage some better improvements while people are incarcerated in federal penitentiaries. and the other thing is i wonder if you can also try to figure out a way to cut the data by state to sort of show to a state the value of doing the medicaid expansion. that you're going to save a lot more money on other unanticipated costs because you've made a way for people to have a pathway to health care. but -- and also, i wonder if you can talk about any best practices in states working with the federal government and states working together to have a better outcome while people are incarcerated and then when they transition out into a state -- into states. so i think you can beef this issue up a whole lot more than what i'm hearing. >> linda, those efforts are actually already under way. the federal bureau of prisons has just instigated a requirement for a standardized release in terms of doing

substance use disorder evaluation. i think we're starting to see that kind of process come down. on the medicaid expansion side, i think the data that i gave you from washington state speaks very loudly to how there's a direct relationship between health care spending, recidivism, and criminal justice spending. so i don't think it's because of a lack of data that we haven't been able to make that push. i think, again, we have to realize that public health and public safety are intertwined and interconnected, and it does not serve anyone's interest let alone the taxpayer to keep folks isolated on an island without the appropriate regulatory framework that we come to expect as part of our federal state and local partnership. so what i would say is the data is there, and we're in the process of the bop trying to implement exactly the kind of thing you're talking about. what we haven't done yet is we haven't made this conceptual leap. that's what we're all here today to talk about. we haven't made this conceptual leap that says we need to figure

out how to build as many and as sturdy bridges between community and corrections as we can. >> okay. bob, last question. real quick. >> bob griss with social medicine and community health. i remember when senator wolford ran for senator from pennsylvania and made a big case about prisoners being one with of the only populations in the united states that had a right to health care. in fact, that was based on a supreme court decision. how does that precedent not create the political power to implement the kinds of solutions that you're hinting at and haven't we learned anything from the tuskegee experiment? it seems like collecting data and not using it is a violation of -- of our civil rights. so where is that -- how does that fit into this problem? >> where are the lawyers? >> right.

>> first, there are several questions and first i have to be a nerd here and correctly select then-synonym warford. it's native americans under treaty and incarcerated individuals are the two individuals to whom health care is a right and not a privilege. in term of the gamble and the supreme court case. what the supreme court ruled was that the responsibility of a jurisdiction is to not be deliberately indifferent to the health care needs of an individual. so, for example, if you had a lawyer going back to your example, debra, waiting a year to get a dental appointment. that dental appointment was made i wasn't deliberately indifferent to that person's need and i go back to regulatory frameworks, okay? that if you, gerngs again, think about how we do managed care within a community setting we require a certain number of days after which an appointment has

to be made, we require a certain number of credentialing to provide care within the context. we don't do that in correctional health at this point and we're still on an island and that's the point that we'll say over and over again this afternoon. >> all right. i don't want to cut people off, but i do want to give us the benefit of our last two panelists. jacqueline, debra, thank you so much. and if you're going to be sticking around anyway, maybe we'll find some stray questions at the end of the q&a for the second panel. thank you so much. >> thank you. [ applause ]

okay. we are reconstituted panelwise. you heard from steve rosenberg. the other panelists on my right, dr. sharon lewis, medical director for georgia department of corrections. she's a board-certified pediatrician and a nationally respected expert on quality assurance with more than 20 years of experience in health care and managed care. and right now she's responsible for delivering adequate and cost-efficient care to the inmates in the georgia correctional system. next to her is dr. asher turney who is the medical director for centurion of tennessee, which is a joint venture of centene with which tennessee contracts to provide health care services for its correctional system. dr. turney is board certified in both urgent care and

and he's got a special interest in health inequalities in the health of vulnerable workers. welcome to both of you, and i would ask -- i guess we need to pass the clicker to the lady who is next. dr. lewis. >> good afternoon. as you all heard, i am a board-certified pediatrician, so i tell folks that i have 55,000 bad kids under my care. what i'd like to do is to give you an overview of the georgia department of corrections which i think is a reflection of a lot of other correctional departments throughout the -- throughout the united states. fortunately, we've had lots of success in improving the health care that is being delivered to the inmates in our custody and

fully respect the astell versus gamble ruling with mandated health care. to start out, georgia has a little bit of a difference here. we're the ninth largest state in overall population, but with the fifth largest prison population. we have roughly 55,000 offenders in prison and about 145,000 probationers. 94% of our population is male and 6% is female, and i think that this is, again, a reflection of other states. the male population, unfortunately has a predominance of african-americans. 62% of our population is age 25 to 45 chronologically and i'll speak a little bit more in just a second about that. 50% is over 35. so you think about your general population in the free world and how we mirror what is in the free world.

we operate 120 facilities, 31 of those are prisons. we also operate county and private prisons, transitional day care and day reporting centers and probation detention centers and boot camps and again, we're responsible for producing constitutional -- providing constitutional-mandated health care. does everyone understand what that is? it means there are basically three minimal standards. one is that all inmates have the right to access care. secondly, they have the right to care that is ordered. and thirdly, they have a right to professional opinions of those providers to order that care. such that the example that i give is that we can't have a dentist that tries to do an appendectomy. so, that's the third piece of it. our demographics are such that 37% of the inmate population has significant chronic illness. that number in percent is up

after about four years. four years ago it was about 33%, and i think that every state is challenged with this where they have an increase acute to chronic disease and the disease that is most prevalent is hiv, cardiac, hepatitis c, mental illness and cancer. 17% of the georgia population receives mental health services and there's some difference with that. in the female population, 50% of our female population is receiving mental health services compared to about 12% in the male population and we think that's attributed to cultural differences and then mostly in the female it is the behavior disorders, it is the mood disorders. we have most of our inmates we say kron logic age, their physiologic age exceeds their kron logic age because of their lifestyle prior to

incarceration. they experience drug use on. they had lifestyle factors of smoking, nutrition deficient sis and lack of activity or meaningful activity. they have minimal to no health care, either medical, dental or mental health and have an accelerated listing of chronic diseases. we have an increased population of aged, blind and disabled. and our older -- our admission age is older. the average now is about 33 years of age and then it therefore translates into our older age of the population which is about 36 years. so we're not getting more young people in that i call, but rather, you know, the older folks are starting to come in. in fiscal year 2013, these are some pretty startling statistics for us. those that are over 35 years of age represent 54% of our population and account for 75% of the claims. those that are over 50 years of

age are 18% of the population and account for 47% of the claims. but most importantly here is that those that are over 65 represent 2% of our population, but account for 8% of the claims. so if you're looking at $180 million budget, that's a lot of money. those that are over 65 years of age and their average claim cost that's around $3500 versus those that are less than 65 years of age representing only 591 and that's a dramatic difference just based on the age. here, i'd like to look at the per diem budget. over the last, at least five years, each year the department of corrections has been given a reduced budget. so we have this budget that is continuing to be reduced. we have the mandated constitutional health care that

we have to provide. we are continuously having an intake of chronic illness which includes those women that come into our population pregnant and we're responsible for the prenatal care and delivery. and, again, they would be high risk. so all of the services that we are required to provide, we are having to get very creative in the strategies that we need to use in order to provide that necessary mandated health care. the covered population that you see listed below represents the population that's covered in our general population. we have probably about 6,000 inmates who are housed in what we call private prisons. there are several prisons within our state that take it so that the cost for that is not -- does not come out of our per diem there. so, again, here's our creativity.

as you heard, i had a long history with managed care organizations. and whether you like 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 what's called the summary of health care benefits. and it is the same document or a similar document that you receive when you sign up for your own insurance. it basically tells you what is and is not covered and is and is not eligible and, basically, what the insurance company will and will not pay for. but for us it lists out what services are eligible to the inmates and which ones aren't. and it kind of puts everybody on the same playing field because the inmates then understand what services are going to be covered, which ones will 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,

for outies. we don't pay for cosmetic surgery, your acne or male pattern baldness. we don't pay for your sex change operation. or your sexual activities. so those are the kinds of services that are not considered eligible. all other medically necessary services, and those are the key words, medically necessary services, are provided to the inmates within our custody. this document has been reviewed by the office of our attorney general and, again, it provides the framework for constitutional health care. the second foundation is preventive care. i know you've heard an ounce of prevention is worth a pound of cure. and we truly believe in that. so it gives us no benefit to deny preventive services. we follow u.s. task force for preventive services guidelines doing routine health assessments providing chronic illness

clinics with all the necessary medications that go with that on a frequency. fortunately, we have a locked up population, so the fact that, you know, they miss an appointment, that doesn't happen very much. they get to come when they're supposed to come. we have a very active utilization management department that does preauthorization and concurrent review and discharge planning. we have an active pharmacy and therapeutics committee. we have a form larry. we have a co-pay which is legislatively mandated and it's $5 for those prescriptions that are considered to be nonchronic care. so it's prescriptions that the inmates come in and say, i want. i want this. i want that. well, it's a $5 co-pay. 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-b pricing for some of our purchases, primarily right now for hiv drugs. we actively manage our network, both of hospitals, physicians, ancillary services, durable medical equipment, prosthesis, 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, ask 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 surgical unit in one of the prisons where for am laer to services we're able to take the prisoner to prison

to have the surgeries done. lastly, we have a forensic unit in one of the ter shear care hospitals that has 22 beds. and the purpose of most of those is so that we have found the more services we can provide behind the wire rather than sending the inmates out into the community, it is both cost effective, cost efficient, and you're first goal is to provide public safety. that is the primary purpose with that. so we do a good job, i think, in providing and getting very creative and providing more and more services behind the wire. our challenges are again, the grain of the inmate population. all states are experiencing inmates aging because they have longer sentences, longer confinements, and all of the illnesses that you experience and that the free world experiences with getting old, our population experiences.

so all the mobility issues, you know, the cancer and all, we experience that. they have physical incapacity and immobility, progressive degenerative diseases. we have an increased concentration of chronic illness and this is in the face of diminishing budgets for health care. and with that diminishing budget, we have to get very creative because there's increased liability associated with that funding decrease. we find that we have to establish protocols of who will get treated for certain diseases because of the treatments being so incredibly expensive. we have an increased mental health burden with dementia, depression, psychosis, disruptive behavior, and the cost of the psychotroepic 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 just being released from prison to come in and provide care. oftentimes they come with no benefits and no resources to help pay for their services. vocational certification and employment opportunities is also a barrier. in georgia, we have a law that basically says that those who become, quote, certified, like a certified nurse 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 including those for sexual abuse and those confined under -- from a sexual sentencing. they have a 1,000-foot yard rule with regard to churches, schools, parks, et cetera. so the recommendations that i would have based on all of these is that 340-b pricing would be made available and much more easily available to the

department of corrections throughout the united states. we would establish guidelines for the potential impact on the departments of corrections regarding the affordable care act so that we're not kind of figuring it out as we go. thirdly, that we would promote electronic health record exchange meaning that, you know, electronic health records would be able to be exchanged through all venues from the prison system, through the jails, on out into the community providers. and lastly, to expand federal funding participation for inmate eligibility to help offset some of the costs within our prison system. thank you. >> thank you. >> okay. thanks, dr. lewis. let's turn to dr. turney. >> 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 ms. bey and ms. rowe, i just wanted to say, we all can have a family member that could be incarcerated. and i want them to get the best care they can deserve. in my experience, i have not had that same issue. as a medical director for tennessee, i work with the department of corrections and we try to avoid some of those circumstances that they describe. so, i don't think it's an overwhelming, across the board pervasive issue, but there are certain situations that, you know, i work every day to prevent. so i just want to say, my discussion today will be a little bit wider in scope and it will be mainly on some of the issues that we deal with in corrections. but as i said, i completely empathize with anyone that has had a circumstance like that,

because that's what i went into medicine to prevent. like i said, i'm a preventive medicine, urgent care specialist 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 qualified health care centers. this is the same population that needs access. and so, it's the same job for me whether i'm behind the walls or not. so, i just wanted to kind of describe our situation in tennessee. i am a vendor partner to the department of corrections. i work with centurion, which is a company that has about 60 years' experience in managed care, also in correctional health care. our parent company, centene and mha services provide us a lot of opportunities and tools that we

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, leveraging technology, predictive modeling and innovative health models to limit incidents and the severity of disease. just some issues to note. so tennessee, welcome to tennessee, everyone. we are a -- department of corrections we have 21,000 inmates across the state. roughly 11 facilities. they have small subunits but roughly 11 facilities. and we do have some challenges. each state has its own unique

challenges and obstacles as it relates to correctional health care. and we have worked really hard to improve some of those issues and make them -- make them more manageable. the population as a whole, just in general, the general population has diseases that affect it, right? and those same issues mirror in the correctional 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 deliver solutions to the tdoc that improve those concerns. centurion has managed the tennessee contracts since september 2013. we have efficiently decreased the number of admissions to the hospital and e.r. by treating on

site, by getting in earlier with our preventive health model to decrease the need for hospitalizations. and trying to set up programs where we get to patients before they have an exas are bags that requires an e.r. run. we've also tried to install what we've done, actually, across the state we've installed electronic -- telehealth, excuse me. and telehealth, just to kind of really quickly refresh is a mechanism by which you can use an internet connection and, you know, video or telephone to essentially discuss with a professional on one side and an inmate patient on the other, with a nurse, and have a facilitated medical visit. and it allows you to get to the patient much sooner so that -- because in the past you'd have to transfer outside the walls. so, we've brought that on board. and it also decreases the -- it reduces the risk of -- to the

public safety of transferring and it saves money from the standpoint of transportation and security. we've also developed some new on-site services which are continuing to improve the overall health and well-being. and i'll talk a little bit more about that on the next slide. i do want to say 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 kind of briefly discuss a few considerations to some of the illnesses. by far, this is not an exhaustive list of conditions. but as we talked about earlier, mental health disease or ill, excuse me, is a lot more pervasive in the correctional population. so we have to bring in innovative, multi-disciplinary

approaches. so mental health, medical, you know, 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 populations -- we'll talk about that in a second -- they have a history of being a victim to violence and substance abuse. and those do make more complicated treatment pathways. as far as unique populations within corrections, i think we all have elderly populations. we take care of them whether you're inside the walls or not. but the difference in corrections is that the elderly population in corrections is physiologically older than their chronological age. so you have a person -- you know, the life expectancy of a patient -- a person -- a patient that's been incarcerated, that's how i see them. i see them as patients. you know, late 50s, whereas the general population is much more

near 70 or 75. so it's a huge difference. so, these patients are showing up to our door much sicker than they would have been and much further along in the process of diabetic neuropathy, diabetes neuropat neuropathy, whatever the worst case scenario, they come in. so it's a lot more difficult issue than probably has previously been discussed. but as far as older populations, we try to look at aggressive chronic disease programs. we're developing on-site, long-term facilities, long-term care facilities to provide assistance to, like we say, a demented patient or a patient that needs continual nursing care. and we're also providing hospice care. of course we understand cancer increases in incidents as we age, so we're having a lot more patients with cancer. so, we're trying to treat those humanely, respectfully on site. as far as our -- i'm sorry. as far as our female population,

females have a higher -- as a group, they have a higher incidence of mental health disease versus their male counterparts. we have less than 1% of the inmates in tennessee are female, but they do have a significant number of medical problems. and it is a different -- completely different environment to treat patients. we do try to bring innovation also to their care by providi providing -- let's say with pregnant patients. we provide centering. centering is a new concept. it's been evidence-based. it show 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 one-to-five or a little 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 preterm babies and larger birth kaets, 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 are -- 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 are going to be released, and we want to make sure that they have -- they have the least issues so that they can have the most successful life and contribute back to society. my goal is not to be the judge and jury. my goal is to provide health care for them. so, you know, talking a little bit more about innovative programs in corrections, as we talked about earlier, you know, telehealth, we can use it broadly for various specialties. it decreases the need for

transfer, including costs of staffing for officers. it reduces the time of diagnosis and it reduces the public safety risk. we also go further to -- pardon me. we also go further to go beyond just the treatment model. we look for prevention. so, you know, we as an organization are moving to more customer-driven model. i think empowering, you know -- if you look at like 20 years ago when managed care first kooim kind of came around -- 20-plus years now actually, but when it first came around, we were more focusinged on providers, networks, facilities. now we're actually focused on patients, consumers. and we do that through wellness programs. we do that through education. this is occurring in corrections as we speak. we have a program called nurture. it's a telephonetic -- it can be group or it can be

individualized but it's a telephonic disease program that provides wellness to the inmates. for example, a patient can actually -- with a nurse as a facilitator, speak with an expert. so, this goes above and beyond just having a doctor on site or nurse practitioner on site. but having an expert in whatever their illness. let's say it's diabetes. you'll have a diabetic expert talk to you and counsel you on mechanisms to improve your health. and it's been shown outside the walls to be very successful. and we're in our terminal negotiations to implement it across our state. so, these are goals that we're trying to implement to improve the ultimate health and well-being of the patients. as far as the future, the future is re-entry in some cases and in those cases we want to make sure we provide a bridge, and

electronic health records, as one of the guests asked earlier, would be a great bridge because it provides the information in an efficient means to get to safety net hospital or a community health care center or to some other group that can provide health care after the patient has been discharged or has sin the sentence has expired. at this moment corrections as a whole does not have that opportunity. there are a number of difficulty in getting an ehr system. i think that would be a potential opportunity for policymakers to finding a way to improve it. because this is ultimately like we talked about, public health and if it can connect to the u.s. public health system in some way, where that information before they come in can then connect to while they're in to when they get out, and it can be a complete pathway or complete life cycle, that would 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 and medical care on sites before and after entry and re-entry. consider electronic health records as a mechanism to -- maybe through high-tech or through some of the other funds that are still available, find a mechanism to assist department of corrections in developing an electronic health record so that we have an ease of communication. it helps decrease unnecessary

recurring medical visits because you have the information from the previous medical visit. often times docs will reorder what the previous doctor has because they don't recognize it has 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 medical institutions to partner and have medical residency programs and medical students and other 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 a difficulty with accessing health care. well, they allow monies available to -- to pay back loans and that's how they can

recruit more and more physicians, nurse practitioners, et cetera. thank you. >> thanks very much, dr. turney. we have about 20 minutes now where we can get some interchange among our panelists and give you a chance to ask some questions as we go forward. remember, you can hold up a green card, you can go to a microphone or you can tweet. and i'd like to get us started, if the folks at the microphones would forebear for just a moment. >> yeah. >> if i could 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 standards -- we have talked about the need for regulation, for oversight of the proprietary providers of health care in prisons or the proprietary prisons providing health care. what kind of a mechanism for oversight and what kind of standards are in place that you either have to impose or live up to, in the case of dr. turney, and, steve, maybe you could talk about the broader picture that go beyond the specific states that are represented here. >> i think part of it just shows the alliance's gift in choosing which states to represent. and dr. lewis because of her personal background in managed care and because of dr. turney and because of the commitment to use managed care principles within a correctional institution has demonstrated the what happens and the effectiveness of bringing managed care principles. i think the question is in both

instances, it's a question of self-regulation that's occurred both in georgia and tennessee that shows the kind of progress that both dr. lewis and dr. turney have created. i think 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 i think what we both heard dr. lewis and dr. turney say because of their personal and personal commitments to managed care, they've been crossing that bridge over to the islands of corrections by using managed care, electronic records, telehealth as mechanisms to cross that bridge. as to whether there should be other mechanisms, i'm going to leave that up to those of you who get to stay here and congress to figure 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 sops, as all

my facilities within the state. we perform annual audits to make sure that they are delivering the health care by the standards that we have outlined within our standard operating procedures within the department. >> we, too -- i mean, the standard of care is no different inside or outside the walls. so, we're held to that same level of care. we have to defend it in court otherwise. what i will say is we internally also do audits in addition to our state -- our agency partner. they do audits on a regular basis, but we also do audits internally to ensure quality measures. and we are american correctional association certified and some of oregon contracts are national health care certified and those also have rigorous standards, similar to some of the quality commissions. >> is it part of your contract negotiations as well?

[ inaudible ] >> actually, 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 got the picture that maybe d.c. wasn't right up there at the top. >> not at the time that they were incarcerated for sure. so, again, ed, this is part of our state, federal and local partnership. that up until now we've allowed each jurisdiction to govern the island of corrections and correctional health as they see fit. and at times they're blessed with having someone like dr. lewis who has a personal commitment that she brings forth. then you have organizational commitments from centurion and mhn they bring forth. i think there is no national

framework, if that's your question, ed, where we have made a societal decision that we're going to make sure 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, in our experience when you've seen one jurisdiction, you've seen one jurisdiction. >> okay. >> i do want to quickly -- i was thinking more about contractual. 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 really coordinate that care from inside to outside that wire, you know, how do we encourage those strategies? what do we do other than create a better link with medical electronic record and things like that to ensure that those folks who are suddenly thrown out in this community once again, freedom and all this time where they were more successful in a structured environment, they made those appointments, how do we encourage and make sure that once they're out they're a part of something? thank you. >> i think a couple of things. one is that we can do a better job as 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. sending 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, unfortunately, we're probably not doing as good a job at trying to hook the links up on the outside. but those patients that have cancer and chronic diseases, major chronic diseases, we try really, really hard to coordinate the care with appointments, at least in the beginning. we give them 30 days of medication to get them started.

we try probably starting six months ahead of time to identify and research what benefits that are available for them with medicare, medicaid, veterans, et cetera, and try to get that paperwork started so that those resources are in place by the time they actually get discharged. >> and, frankly, i would say we're seeing a major difference between expansion and nonexpansion states on this. an expansion state it's much easier to create that linkage out into the community because these folks are being able to come out with insurance. the nonexpansion states, i think both dr. lewis and dr. turney can speak to some challenges they're having, to have community providers see basically what will be a no-pay patient. >> go right ahead. >> just -- >> you want to identify yourself, please. >> i'm a long-time, lifetime public health official. and in an expansion state. and it seems to me that a real lever is certainly consumer education but also with the state contracting because in an expansion state, the state is

paying for corrections and the state is paying for medicaid. so, in order to coordinate those benefits on the hospital side, we're looking at accountable care organizations so that hospitals are coming out and working with community providers to make that providers to make transition meaningful. maybe someone is aware of those innovations with following the individual outside of the facility into the community in a contractual arrangement so they're sharing by the public health officer. i ask if there's any examples of that sort of innovation. >> there is in oregon in part of their cco they set up a separate post-arrangement. 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. i think that's a great example.

again, i think the question is that given our federal system, our federal, state and local autonomy, the question is, how do you stimulate and how do you encourage those kinds of programs? is that a federal grant program? is that an initiative program? how do we do that? it's an excellent point. >> thank you. >> do you have a question? >> yes. here we go. thank you. >> hi. i'm with the national association of community health centers. my question is mainly to mr. rosenberg, but anyone who has input. as a staff member, we have thousands of member health centers nationwide, including those in partnerships. in addition to your island metaphor, i want to point out that the correctional system is also hidden behind concrete walls, layers of varying policies at the local, state and federal leave they'll are gray at best, the inmates are disappeared behind the walls and

the label criminal and there are financial incentives to keep it that way. from your experience of success building these partnerships at the community level, i'm wondering if you have any words of wisdom and lessons learned that you could share for us while we're at this national level but then have the local member health centers that could potentially want to reach out and create partnerships but might not know where to start or who to contact? >> i want to identify a huge obstacle which you know about which hersa has been unwilling to let them have a change in cope of service. so while you have the health centers that may be actually the number one appropriate provider to be going out and providing care behind bars, they have not been willing 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 -- you have to remember community health centers are 51% user boards. having that community board understand and identify that the folks behind bars are members of their community who are temporarily displaced. i think that's a huge educational process within the community health center movement. i think that if you look at the work of one of our board members in massachusetts who started this model, he started it by him identifying that the folks in his county jail were community members temporarily displaced. he reached out to community health centers and invited them in to provide care. that came from the correctional size. i think the challenge is from the health center side having an educational understanding that these are the fathers, brothers, uncles of the women and children we serve.

and that they are part of our community and we want to reach out into behind those wires and walls to figure out how we create care. an initiative on care is a good model. >> so my name is amy thomas. i work for the association of community affiliated plans. we represent 58 non-profit managed care organizations. we have one in rhode island working with their department -- their health services department as well with the prisons to help with that handoff between the prisons and them coming outside. i particularly was curious if you have any research about the return on investment. we're looking at this in rhode island. but any research that's been done about how the handoff saves

medicaid -- state medicaid programs money. >> the answer no, because of data sources. so the washington state data i was able to describe to you is unique because they merged their jail booking data, their medicaid data and mental health utilization data. they have a master patient index that allows them to tie that data. no other state has that data at this point in order to be able do that research. i think in rhode island, you have been blessed. you have a leader. they have understood and been working with trying to figure that out. we have something similar in the state of vermont right now where there is an effort to figure how to link the systems. unfortunately, without what we call the master patient index or some way of tieing that data together, we don't have a way do that. then there's a lot of hippa concerns and other concerns of being able to do that. they were able do that in washington again because of their unique data set that allowed them to identify folks.

>> we have just a few minutes left. i'm going to ask you as we go through the last couple of questions to pull out of 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. >> a very quick question. i think both of you talked about hospice care and long-term care inside prisons. i was wondering why can't these people be released at that point? why are they still incarcerated when they probably are not a threat anymore? just wondered. >> for georgia, i can speak is that our clemency entity, the board of pardons and parole, has the authority to decide whether someone is eligible to be released. we have a very active medical reprieve process. we probably about 65% of those inmates that we submit for consideration that are being granted a reprieve.

those inmates who have as i said a guestimate life expectancy or a disease that's costly to the state, we can submit those for consideration. >> we have a similar process in tennessee. but that is actually -- our providers would be responsible for providing those cases to the department of corrections. they would go through the normal process. the process has been recently revised to include some long-term issues that are not terminal but are debilitating. to be humane. >> maybe this is the last question. it's maybe the toughest. we have talked around it for a good part of the conversation. what impact do you anticipate

the new drug having on correctional healthcare expenditures? >> easy answer is bankruptcy. >> therefore, what? dr. turney was talking about trying to deal with a very large incidence of hep-c population. are you going to prioritize? are you going to test everybody? are you going to allow the use of this drug for some subset of the folk ss? how are you making that decision? >> we're going to -- and have started to prioritize the inmates. basically, leave the decision to the gi specialist who is rendering the care as to who is

most appropriate given the financial constraints. it's a very effective drug. but to treat an inmate with fewer side effects, which is the big plus for that, we were talking about it roughly $120,000. 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 heart disease and diabetes and everything else. so, yes, we do have to prioritize. we have to follow protocol. we are currently looking at the federal bureau of prisons guidelines for treatment of hepatitis c. >> asher, you want to weigh in on that? >> it's not an easy answer. i think that we still have a long way to go with the discussion. there has not been any definite defined schedule that have been released on a national scope.

they have released some preliminary guidelines which we also use. we have an advisory committee that has an infectious disease doctor to assist us in prioritizing patients based upon medical needs. hepatitis c and hiv, they don't work well together. when you have both illnesses, your disease goes much faster. so they are put at the top of the list. we look for worsening clinical courses. and we put them to the top of the list. pry prioritizing. there needs to be discussion between local, federal corrections and public health on this discussion. we really need to find a solution. but it's got to be collaborative. >> okay. well, if you could put that slide back up, i would appreciate it.