college or health plan innovation or some of our consumer and primary care work that's under way. care choices, just to give two sentences on, is a model we launched were beneficiaries for the first time ever will be able to receive hospice and services to improve quality of care and patient experienced and lead to a more efficient health system. so what can we collectively you do together? focus on better care and healthier spending for the population and that you serve to invest in the quality and data infrastructure to focus on transparency. those plans are a major driver to positive change we want to have a culture of collaboration, a partnership

and improvement. it is a three-year journey. but they pursue rubio, banks for having me here today and for listening. [applause] >> you could see the whole range of things they're doing it duse incredible. well done. now we will hear from andrew one of the most innovative not-for-profit plans in the country. and now widely adopted

quality contracts. a key contributor to the successful launch of the of health reform plan. and of last health care reform optimist. to drive positive change in the state of massachusetts. >> they give florida state this event today. i will share time to speak more slowly. [laughter] you heard about go work with the delivery and this is a reform.

if by doing bad and we have doing that we have rigorously studied a model in the nation and actually around the world that they try to think of payment reform. with those coverage reforms that health insurance levels are a the highest in the nation. in the time it where is hard to ruth talk about.

and the result of a architect just do delay because for decades those in the country the progress was held hostage and said the cannot extend coverage so coverage was never expanded. so after the law was passed massachusetts started to turn their attention with that powerful item that we had was the paper co to say you already are so far ahead but we are behind it could be the most expensive place to deliver health care in

the nation. so bad lacrosse's and what could we do is the largest commercial paper in the state to lower cost and improve quality? this is also a time when a patient safety and quality improvement was eating women time so what we want to do is designed a payments system to approve quality and lower cost. so we hired a consultant. [laughter] tuesday's coordination with the most effective pavement model to come back with the 250 page report to say there is no such model.

very disappointing so we had to invent one ourselves. >> we put them in the remand we called it the cave. and here is what they came up with. we decided we had to move away from the system and not pay for the health but as the primary-care practice to successfully manage a chronic illness was kept out of the hospital. if there were not doing a good job we paid them more isn't that backwards too

wanted to change that so we started to establish a budget based on all medical services, medical care prescription drugs, a shared risk model you have to be on the decline being trend for pro 64 daschle a recognize quality measures validated and to also try to disrupt that adversarial relationship where every area you have a negotiation let's go where rework together so we had a few pioneering plans to table in

with groups and over time it is now the standard way to pay for care that now is the standard care. what happened to read 2011 that was such of big jump for word? pyrrole leaders of massachusetts i will talk about results as the quality is that this is the principal way to contract and not require you to do this. to keep the fee-for-service pavement's extremely low.

and on the front page of the major daily newspaper but although i did not intend it this way that there are other in their mental factors as well. as the fever system became less attractive the budget system became more attractive. this program we want to change the name because with a big success it would have been called blue innovation or blue skies. but it is too late. but the acrid and had already stock it was called the 8qc and is now around the country.

but it is the most regulus -- rigorous so a team of researchers had been publishing results on a the aqc annually and consistently if now increases quality in all types of provider groups are succeeding. academic community and the practices that serve low in kong vulnerable populations to meet the targets these results published luck -- last october in the early years of the studies we have a classic controlled experiment those in the aqc and those that were not as so many were in we had to compare them to other groups

outside of massachusetts and by number for compared to the control medical claims spending was a full 10% lower. a similar story of dramatic changes. researchers observed over a number of different domains and there are to hear, while national numbers stagnated stagnated, our physician practices improved dramatically. some of the aqc group's nine out of 10 diabetics the proposals under control the national average is 70%. that was the early results but when it looked at our products about half of the

members are with hmo put the rest is pp of the most dominant form of insurance through the country but weaver getting questions from other plants including the government with the hmo population when they enroll have to choose a primary-care physician. so we spent two years back studying the problem now we come up with a solution and we announced earlier they were expanding its now those covering to produce 50,000 -- 250,000 are joining the new model. so the you receive the call that the doctor laid out 40%

of payments nationally in this alternative model. we're already there in massachusetts 40 percent are under the new models. what have we learned? obviously before i get to the use you have heard about physician leadership, a change of culture having meaningful financial impact impact, and a long-term investment but i will focus on learning and support. how are we supporting our position to be successful? and what that does to the changing role of health plans like mine. the issue the doctor talked about that is a big barrier i will tell you how we did

that then finally how we change the model over time. the first test to do with support we provide our physicians with daily, weekly, monthly, quar terly, a newly reports of other patients are bearing your patient was admitting last night and you may not know that to very detailed statistics about care patterns from a chronic illness, hospitalization, th ese reports have been designed in collaboration with physicians and they are using them extensively to change care as a result. but it turns out there is a great desire of shared learning so regularly

convened groups of our position and practices together you may recognize the noted author and colleague of mine talking about and of life care how that could be improved improved, separate groups medical managers that come together to share learning experiences in and can call their own physician and leaders for communication and support. these payment models have grown and flowered so well those of the system were excited about that. this is a strength of the blue network nationally so now we have reforms or others around the country putting together a national network of paved reforms. what does this do to plans

and providers? most of you know, in the '80s and '90s health plans like ours have intensive care in disease management capabilities because of the delivery system of patients were not getting the connections or the care that they needed on a population health basis they now take accountability for that management so should a nurse stationed be calling patients to remind them about appointments or talk about relevance? or should that be more logically placed inside the practice themselves? we are working that out. this evolution will change

the world. on the issue of retribution i know some of you are policy experts but this is the key question that seems tactical but if reform can working physicians feel they're held accountable for the right population progress remove from hmo where patients choose primary care doctor and their ppi product we have to develop the way to attribute numbers to accountable groups to work with physicians and other local health plans to improve accuracy and then we did important things. the agreement to physicians to say are the use your positions? that is an important way to

validate the model. to give them confidence when we start paying on of budgeted way of population health for members have not chosen a primary-care physician to say these are their patients. but to sustain a model over time we had one interesting innovation to use each quality measure to drive their share of risk so better quality scores they meant there would repay a smalle share of the cost overruns or fake to keep a larger share of the savings so often the efficiency incentives and quality incentives are separated but we could join them together that innovation has been well-received.

you also hear reagan of a about the cacophony of measures that are out there for quality. we have been very focused to narrow those measures from 64 down at 50 and also the next generation once that we are very separate -- excited in the next model our patients reported outcome measures their own experience their functional status, power they doing emotional health to be rewarding position and practices of some of those measures that patient's care the most about. we wanted to have a learning culture so now we have six or seven years' experience to read know what is working but we know we can get

better so we created a model that is flexible to continue to innovate we now have a powerful chassis of collaboration of better performance, higher quality, lower cost in a way that works for patients and caregivers. thank you very much. [applause] >> para neck speaker is chairman and c0 of florida blue he leads a family of four were thinking companies including the state's largest health plans are being 7 million and provides medicare payment services to 12 other states. is leading the transformation from an insurance company to grow this company with a strong focus on health and wellness

and prevention for girl improving quality and value and serves as the chairman. [applause] >> thank you cheer everyone for putting this forum together. doing an outstanding job about payments i will spend some time talking how payment reform falls into the broader picture of changing the health and health care system in the country because if you step back, looking at the question in front of us as a nation. i don't believe it is a political statement but i believe something we're passionate about that all

americans i don't think it is a political statement of where we should be as a country purpleheart we get there is the debate but at the beginning of a health care reform discussion we talk to reforming the delivery system, outpatient access care, insurance and the debate got narrower as the discussion moved for were due to political factors but let me take you back to a broader picture. our company is a $12 billion operation handling people in florida also medicare payments that is $108 billion of medicare payments in that business unit alone so we have a tremendous amount of data to understand what is happening in the system. as restructured our

organization the blue cross blue shield in the state of florida is florida blue robo we created three other one is guide roll hall where read to direct delivery of health care and own a variety of health care assets. died well connect is reduce the retail business to focus on the consumer how we have delivered health care in the nation and the delivery system because the convenience was to doctor or hospital or somebody other than the patient we are big power to be transformed them to be responsive and guidewell source is the medicare payments that is of

a company is structured so we look at the old world and fee-for-service medicine designed for volume the more you do the more you get that is the system we have generated therefore we have much overuse and a lot of spending that is a necessary. to date the new world has much more pavement alignment and a system that is focused how to utilize the data that we have, the technology, and we look toward the future growth as your truly innovative with partners as we spend more time on what should one organization do versus another? there's a lot of redundant activity and how to refocus on population hall?

and more about how do we work together to drive for better results for the people we serve? >> we think about this and much more holistic way how we use data and of the technology to drive through accountable organizations and we have a variety of those across the state of florida. i understand now refocus around the'' -- the twin cities of florida is a whole other story. you know, miami and jacksonville or to defer universe. [laughter] tampa and orlando are very different places so we have at least five regions that don't act like each other with a different ethnic

makeup different history and delivery system on the ground which means we have to be very sensitive to the geographic, cultural, a background needs so our delivery model varies all over the state depending are rarely deliver the service. fisker issue the generation of things we think about like how to use virtual care. they talk about televisit with the fee-for-service that could mean someone could spend a lot of visits because they have access through the telephone now so you have to be in the world of payment reform for that to make sense so to create

efficiency it needs to replace the visit in the office but only because historic feat that is rather provider was paid so you wanted the service you came to the office. we say think about where our kids will be we have the privilege to go to the doctor's office to wait them the exam room to wait to. may be having that comfortable sealock to sit on the cold table and to see the physician to get a written prescription they have to go to the pharmacy to wait. our kids will not accept that. because everything happens on your smart phones so why should medicine me any different? we talk about most medical

happenings will be on the phone with the doctor that transmits your bridles you have the visit they go to the pharmaceutical prescription that you pick up your convenience because the system is built around you and not the delivery system more will happen that way and. paper co talking wrote the different regions of the state's, we literally have what is going on the same geography with differences because the system is so large and fragmented it will not consolidate overnight but insteps. primary-care alignment replacing with hospitals

intermediate bubbles of care and to looking at a variety of ways to deliver care. we have the first model that is the firm of south america we believe the first time u.s. company contract with the non u.s. firm to deliver health care in the united states. think about south florida. increasingly people from south america have landed on our shores living in south florida. this is what they know very well precontracted with them to deliver medical clinics. they're building seven more over the next 18 months. culturally significant and sensitive in the community

the first is 80% hispanic population everyone speaks spanish. a clinic belt with the understanding the family matters greatly in that culture and often they come to the clinic together. rebuilt waiting areas that facilitate that and one-stop shopping thinking of primary care, emergency care mammograms, mri or specialty services solemn place because in south america there used to getting all care in one place a lot of people from other cultures will like the idea of one-stop shopping everything in a single place? and you see the doctor in 60

minutes from when you enter the state -- the site. if you need follow-up care retry to do that immediately it is dramatically different care. remember the patient a different way to think about care. we are excited about the clinics and they have been warmly received. the next one is guidewell emergency medical. why would reduce that? is the emergency place - - room the place you really want to get your care? honestly? [laughter] they are not built around a patient, do not deliver for the patient, of so we built across the street from the hospital because it is admitting multiple of the number of the people that should have been following

very rich in zero visits many consider it a front door to the hospital and as a way to fill the beds. many people should not be filling those beds but get the care they need, but quickly, high quality and going home. we created this facility to do just that and it is resonating parts of the patients a quality care, well delivered, a creek and i am satisfied. we're disrupting what the hospitals are doing by putting the facilities in place. to allied health care eight organization if you follow there is an organization that did a very, very good out reach model and sold their organization and now

is the alignment health care we have created contracts with them to take care of the chronically ill patients in concert with primary-care physicians. if you're running back practice with chronically ill all seniors you work in concert because of the intensity and obeys folks are very oriented to a that ended is a partnership model so we will do a better job for our seniors. when you look at the size of the state of florida towards being a 20 million population we're already the third largest date in the nation we have to do more to

reduce debt to patients centered homes 700,000 patients today are taken care of in the alternative care model so we're on the path to the targets laid out a short while ago. retail centers. think of the insurance plan or insurance company, for a minute suspend her you think of the insurance company. we said we will make it a health solutions company and one calling card is the retail center look at this facility we have 18 of these across the state of florida. so what happens? think of the affordable care

act you can buy individual insurance but you could also walk in with your claim that has not been resolved and we will resolve that. people say insurance companies are hard to get a hold of the we put ourselves on the front line to walk again to resolve this face-to-face. we will teach you how to use the online tools people assume and then they think the customer will know how to use it even sophisticated people say can you teach me? we will walk you through so know before you go you can go online to see what the service cost, and know what is service cost, and know what is covered and how much your piece will be purple one of

the great questions is daiwa to know in advance my responsibility. we teach you how to do that. the next is care consultants. held the role this programs that are tailored to the individual through consultation through the things you should be emphasizing 71 of those entities could be used. last year 350,000 unique number of visits. before an insurance company building on the skyline but now we in gauge our members each and every day. customer satisfaction is 92% that is the number to think about what your insurance

company? go to care consultants, 97% satisfaction. last year the blue cross blue shield association award for the highest number retention level in the nation because they either have encountered the space are has contacted us face to face or they know that they can. we also talk to the mayor and the civic leaders in each community to say what would you like this to be to serve your community? read your reading program in orlando literally a of letters -- literacy program the kids come and to leave with a backpack flooded love books and but that is

another issue. have a need it to engage to see the hero's read to them. >> you get yourself with the help solutions company. >> yes there are financial model. >> yes there is the head minister did focus that is all captured on this slide but help is much bigger than health care or being engaged with people proactively to talk about staying healthy in the first place and what drives that is literacy, the ability to go to a school

that has a gm program we advocate for those because our mission of help as much broader than the payment on the back and. so we have been a partner outside of orlando. funding partners were johnson & johnson, a ge medical, florida a blue guidewell as the founding partners. this is to now has the innovation center. >> newt to defend the ability to work, are prayerfully and a dash of

the expense to the marketplace and to convene discussions around the issues like how to resolve the primary care shortage? integrated teams can make that happen but what are the best models? one of the things we know when rigo to tallahassee they have a huge agenda and how can they possibly know enough and route we will be doing as we convene we will bring legislators to the forum to learn about the issues in greater detail. >> so we see our mission as broad, a huge stakeholder to drive the system to change

the quality and innovation. [applause] >> that was very inspiring to think about. and try to find the solutions to get us there. now we will turn chiru who who has just returned from his honeymoon of weapon interesting background includes medicine and finance. a leading conservative change agent and is sought after presidential campaign an adviser in praising marco rubio as previously a vice mitt romney and rick perry a principal author of the apothecary, a frequent commentator on numerous television shows.

[applause] >> i really enjoyed what they had to say it is inspiring to see with people focused on improving quality and delivery of care. has ben difficult to prove but the a great work that both of your doing. but i will talk about a different issue of the high price prescription drugs. this has spent a concern for decades and what i want to to argue today one of the challenges it is seen as

ideological or partisan issue and i say it shouldn't be it is important for both parties to put their heads together to think about ways to tackle this problem it has been difficult to prove expanding coverage improves health but innovation and prescription drugs does. just book of the cholesterol lowering drugs to reduce evidence of a heart attack at a fraction of what we spend on conventional health coverage. the more we can do to expand at an affordable price makes a huge difference to the access to quality health

care and i should make the disclosure i am revising senator rubio but please do not associate these views with the senator he would get very mad at me. [laughter] there are too over simplifications that have dominated the debate about prescription in drug pricing in the united states. the first is it is all about greed because of for-profit companies are greedy and they are exploiting the fact we don't have price controls were other government measures to prevent

profiteering and the poster child for this right now the ceo as recently profiled for increasing the price of an old drug used to treat toxoplasmosis. but here is what is important to think about if he is the reason why they're so expensive than car companies are it theoretically a greedy. so what makes them lessor board banned drug companies? why don't we need price controls? widow seemed to be a battle there just as motivated as any other drug company. why have price is gone up so much? or are there other economic factors that play?

>> it is important to understand we talk about the last full months but the new treatment for hepatitis c you can see the dark blue band is the increase the prescription in drug spending last year due to new drugs mostly multiple sclerosis and the price increases for the drug is already on the market often five-to-10 years. and that is a bigger driver in the new innovative drugs. it is the older ones where they choose to air charge more but the example is egregious and exceptional but a very common practice for drug companies to raise

the prices that have been on the market for many years. the other theory is that innovation is expensive and why we have to charge will be charged. mark sector berg is laughing at that theory because his product doesn't cost anything to use it as a user. google search engine cost nothing to use it on say i have to charge to $1,000 otherwise i cannot find innovation. you'll never hear a google or facebook to say that so why isn't that pharmaceutical companies argue that high prices are necessary for innovation? in fact, in most sectors it

is low prices that drive innovation. the whole point is that hot most innovation happens at the bottom of the japanese car companies came here they did not compete for the luxury market but the most affordable car like the honda. as they would gain market share they would move up now they make acura and did the idea of the lexus but first they found out to deliver the high quality car at the low price then moved up after that. so that isn't happening as much in pharmaceuticals. take another case. you could say it is software, internet companies were if that is different.

what about apple? they cost more and evolved over time. so volved over time. so is hard to believe that the first was only eight to years ago then added 320 by 480 screen and it cost $599. the most recent premiere was launched with 128 gigs of memory so 16 times the amount of 13 and a half times the resolution and

cost 27% less than the original. what was the last time you heard of a new drug that costs 27% less than of the standard of care? by that standard is has failed to deliver value and innovation at a scale we receive from their retail technology industry. hearing is an example. and peter is discussing the evolution a truly innovative drug that was the harbinger that we now experience party in a that targets the

molecular defect and cares leukemia. at the end of the of life it more than doubled when it was charging when it was launched despite the fact to other similar drugs launched over that timeframe including a drug that was manufactured. historically there will say i will raise their price of my older drug to meet the new drug less-expensive so the insurers have the incentive to move the people of the older drug then if

that goes off everybody is on the new drug and companies have been using that technique to extend the life of their franchises. it is perfectly legal and insurance companies are going along with that but that is the reason why you see the older drugs go up over time if apple said the i pawed from 2,001 they will charge to a half times for that today and 2001? we would think they were crazy but this is what happens in the pharmaceutical industry. this isn't because of greed or innovation actually because federal policy has distorted the way we pay for

it used prescription drugs in such a way that those don't apply to prescription and drugs. the most important thing 2.0 is this isn't a matter of affordability for people who need them. misspent $2 trillion a year in government spending and the big part is we subsidize the cost of health coverage through medicaid a andretti care program but also to the tax exclusion the value of which is just as large on medicaid or medicare so if you include the lost revenue

from the employer tax exclusion and add that to medicare and medicaid we're talking about $2 trillion of subsidies every year. is it any surprise that providers charge a lot no ring the consumer comes from those consumers? i have simplified their data health care and everything else. the blue bar is defense, or bridges to know where, unemployment benefits , their bread is health care.

and their rubio a significant crisis their prescription and drugs are a part of that and it can be avoided. so the point i want to make is better is the assumption is that you shouldn't mess with the way we pay for prescription and drugs in america today it is buying is a free-market capitalist system but it is not it is not a free-market system with a 10 year old drug costs to and a half more than it did 15 years ago when it doesn't increase the value to the patient. free markets work by delivering better product and a lower price with more quality overtime and and we should be holding the pharmaceutical companies to

that standard one of the biggest reasons don't have a free market today is retold pay for this stuff directly is the biggest driver because consumers want affordable product and they demand it it is not they don't buy it companies have a huge economic incentive to deliver those products at a lower price point with more quality. what we don't talk about is a regulatory mandate that is the president for the health care system the aca requires that insurance companies cover branded drugs regardless of they are more effective than generic alternatives products are

required to cover and there may be cases where that is separate it is better for a fraction of the cost to lower premiums to rationalize their formularies where they should. . .

obvious that the clinical value is there. where it is, great, but it is not always. the 2nd very, very important area is that it is extremely difficult to develop innovative new drugs. the fda has gradually layered on more and more requirements to the point where it now costs an average of $2.6 billion to watch in a drug if you incorporate all the times drugs failed and development for every one that succeeds. there is also is also the fact that of course, there are patents. the patent extends typically on average about ten years. it does mean there is a

monopoly and that can be a barrier to competition because it is otherwise so difficult to develop. when the free market is allowed to work it actually works very well. one thing we don't spend enough time thinking about and talking about is the fact that for all of the complaints about the high price of branded prescription drugs, the united states leads the world and the percentage of prescriptions that are actually generic because of a visionary law passed in 1984 right representative waxman senator hatch drug companies in the united states have much broader access to the patient pool once a drug goes off. cholesterol drugs went off patent.patent. generic drugs came in and took over that market at a

fraction of the cost. it cost less to manufacture most generic drugs and it does a bottle of water or can of coke. that is a major driver of value our system compared to our european countries. the idea of substituting their products for older branding drugs is much more restricted by regulation. today 90 percent of all prescriptions in the us upper inexpensive generic drugs. it is importantit is important to understand in context, while we are concerned about the high price of branded drugs the price of generic drugs is very low and there is a lot more success in the united states for that issue. and insurance companies are getting smaller about -- getting smarter about delivering generic drugs to patients by steering them -- steering them to cost effective drugs. so what can we do to improve where we are? as you know, hillary clinton has performed -- proposed

drug pricing to tackle this problem. her proposal would make the problem worse in a lot of ways. it was further subsidize the insurance coverage of pharmaceuticals in a way that would leave drug companies this accountable for the economic value of their drug. it was shortened the patent life of pharmaceuticals in a way that will make it harder to develop innovative new drugs, and some of the things like importing drugs in canada won't have much of an effect because it's 110th the size of the us plan drug companies are much more sophisticated now and restricting a majority of those countries that you can't import drugs. so even if you could, it would not have that much impact on the us market. and importantly, she did nothing on fda reform, which is one of the principal problems that drives up the cost of healthcare come and nothing on regulatory reform which outside of fda reform is extremely important problem.

so what can we do to actually solve this problem? it is simple. let's do more to reduce the barriers to entry for knew computers, competitors, reform the fda we have as you know in the house. that is a modest but good step to actually removing some of the barriers, the competitive entrance and disease areas. we can level the playing field between branded drugs with patents and insurance companies. today insurance companies are barred by regulation from mending together to negotiate with drug companies. private insurers. if you don't have my drugs, but this guy does, you will lose your patients so they feel pressure to cover drug when the economic value is not there. that companies band together and you would get a much more economically rational result and can do more to allow people to shop for their own health coverage

because that gives health plans more of an incentive to rationalize there drug form not just with drugs but with doctors and hospitals, two to deliver that insurance product at a cock to come in a cost-effective way which will lead to all sorts of downstream effects of plan design innovation and better value for patients. if you want to hear more about my thoughts on this you can download these various documents and with that i thank you for your time and look forward to your questions. [applause] >> well, that was thought-provoking. just to be clear, we take no positions on the election or any of these items. we like to have different perspectives in the room, and that was excellent and thought-provoking and now we are going to hear from hoover reinhardt who may have some different ideas. again,ideas. again, we like to have all of the ideas out there. so now it is my pleasure to introduce the james madison

professor of political economy at princeton university. he is recognized as one of the nation's leading authorities on health care economics. he has served on numerous prestigious commissions, advisory boards, and editorial boards, and you can see more about his background in the packet if you look at his biography. he is a prolific author and original thinker with prolific author and original thinker with a gift of making rigorous, complex, economic analysis accessible to students and all of us here. he informs public policy and public speaker and blogger for the new york times, forbes, andtimes, forbes, and gemma. talk about a wide range of outlets there. he is the longest-serving advisory board member, and i have had had the pleasure of working with them for over 22 years. it is a warm welcome that i offer. [applause]

>> thank you for this warm introduction. sheila says she likes to have stuck in the garden party. i said, that is why god created me. my slides up? i can see them. this. okay. so if you think about innovation and health care, there are two areas. one is biomedical research, the one that was just being discussed, and the other i would call operations research. every industry have -- has not. health services research which is aimed at improving the efficiency and patient safety with which healthcare is delivered, including drugs, and these are quite different areas. on the biomedical side the advances have been breathtaking.

even more breathtaking. we could have more. the viagra pill last 50 years, for example, or something like that, but the reason we are the leaders, and the us is the leader in this field, as we have great scientists, and if we do not grow them we import them. we have a flourishing venture capitol market such as no other country has, and every year we spend tons and tons of money on supporting this particular kind of research, both public money and private even more so. when it comes to operations research, that is the stepchild, which is amazing to me, very few industries would spend close to 3 trillion a year and spend

as little an operation research as we do in healthcare. as i said, the total federal spending on research and healthcare is about 50 billion. these numbers come from academy health switch. 2 billion is on health services research. .07 percent of total spending more for every $10,000 seven bucks on operations, not a lot. so in general we have paid for this. many others, we spend a lot

of money roughly with the exception of switzerland, twice as much as most other industrialized nations per capita, but everyone now agrees while american health care can be splendid, overall we don't get our money's worth. that is not generally agreed. so congress, i think, has allocated a pittance to operation research command i don't quite understand why that is. so theprivate sector has underinvested, too, but there is a theory of public goods. everyone in econ 101 knows it. if i spend money on something in the benefits are a crew to others who did not spend money on it, i will underinvested in that activity. that does not mean private industry is evil. they just own up to the theories we teach in econ 101. [laughter] and it gets worse.

it took us years to establish the agency for healthcare quality research. i was one of the actors trying to get that established to get operations research to get patient safety and quality and healthcare, and yet of recent there have been talks at some point to zero out the budget of that agency or at least to cut its budget drastically. i think it is penny wise and pound foolish to do that, and that agency gets about 400 million per year which is .016 or $8.60 for every $10,000 national health spending. if you think that will solve the deficit problem that was being discussed,discussed, i have news for you, but that is really a shame. sometimes you get the impression as if congress is

actually encouraging and efficiency or at least don't care about it, and they should care about it because healthcare is breaking the nations back. congress might pay some attention to the efficiency but also to patient safety. this morning at breakfast in the financial times i saw kilian ted said a revolution is underway in us medical service. when you have gray hair like me you have heard of these revolutions many, many times i have a slide that i decided not to use. it is a thing that you put on at these conferences because i have heard this now for 30 years. i think that there will be progress, obviously, obviously,progress, obviously, and the use of it and all of the little startups, some of them will pay off, but the progress in

this field will be much slower for a number of reasons. this i already said, i have heard microsoft and google and others nibble at the fringes of this per call but i have heard them for at least ten years command i have yet to see the major fruit of that coming. so the word is not revolution but evolution does not mean we should discourage it. what hurts wonderful presentations from massachusetts and for a reason i said that, well, 70 years ago we invented a

wonderful thing in america call kaiser. i still believe that is a way healthcare should be delivered. since we already mentioned it, why reinvent something less good? i don't get it, but i'm just an immigrant. but there are other reasons also. very often the innovations in operations races on healthcare delivery change, they are disrupted. disruptive innovation as if it were a good thing.

i'm the guy whose life gets disrupted. so therefore there is going to be resistance to a lot of these things command we should always remember one person's efficiency is another person's income loss that happens. and so i should wonder if k st. isk street is populated with people who devote there lives to perpetuating in efficiency and american health care because they are paid to do so. so for all those reasons. now let me say a few words. i obviously disagree. first of all, i will agree with him, getting, getting a pharmaceutical product to market is more difficult than most people realize. you really have to run the gauntlet. i have a design.

you start thinking of a theory of the compound which is preclinical and that it is phase i with a trying on humans to see if it is safe. phase ii they like and efficacy. in the 3rd phase is effectiveness meaning, if it were applied in practice one that actually be effective? and then make an application for approval which takes many months and sometimes years and finally a drug succeeds. but at every stage the bulk of them die. it has been estimated at a 10,000 tries they get started, one or two make it

to the end. so that must be understood. the dragon makes it all the cost of the failures, the dry holes in the auto industry that we had along the way we had to add to it the opportunity cost of the money, the finances that you sunk into it. to an economist that is is really cost. if i can earn x percent by putting my money into a high button this method in the drug development i must at least get compensated for the money i didn't make putting my finances and some other things. so therefore the billion-dollar price tag, one can argue about it. many drugs has between one to 2 billion to develop.

i believe that. that's easily demonstrated. so that much is true. the interesting thing is all one reason that drives healthcare cost is, we are extremely finicky when it comes to drugs drug and devices are help to a verya very excruciating standard, more in the us than other countries. remarkably when it comes to other areas of healthcare we see much more relaxed. this is 1999 when the institute of medicine came out with a study that said anywhere between 50 to 100,000 patients die prematurely in american hospitals from avoidable error. imagine if a drug killed

that many people? all hell would break loose. the latest study, 400,000 patients died every year from avoidable error. that's what it says. so i wish it weren't there. then for the drug industry the kills five people who thing i don't understand i talked a little bit about the pricing. the pricing, because we're

producing drawings of investor-owned companies with venture capitalists we tend to think of the pharmaceutical company as the quintessential examples of private enterprise. here is my view. that is the drug industry that sits in the protective hands of government way very few other industries can. what are the protections? not only the nih money or is spent, but patents, market exclusivity, they can give you more years of market exclusivity, data exclusivity which means a

generic company cannot use your data to do research. prohibition of resale of drugs among customers like we can go to canada with the drug, and there are other subsidies. it's a highly protective industry. and when you have that bird in the hand sometimes they want you to chirp a certain way. you better do that. price control will be very difficult. they really know that would be complicated, but you could call for coming to that i want to say that the industry now talks about why

you pricing. you know, our prices incidentally no one's prices, no industry price is ever set on cost. if it happens to be equal, that accidental, you don't price on cost. you price on what the market will bear. cars are that way, diet coke is that way, everything is that way. drugs are that way, too. they call it value pricing. the problem is, what is the value of a quality adjusted life that we could buy with drugs? we don't know. is it a hundred thousand, 212 million? we are too shy to even discuss it. and the drug industry, they can then say let's just see how high it is.

we never say no because the minute i say no and i know that is the maximum price i put on human life and i look like a fascist. so it's a very difficult thing to do. what could be done is when the price looks unreasonable on its face, not price control, but when it seems unreasonable to say, all right,say, all right, you can do this, but we will market exclusivity. we nibble away at this or data exclusivity or one of theirother benefit and protection we give you build take away. that is not price control it simply says if you are to unreasonable with your price

, then we have these other methods. and i want to give credit to lyn mikel zeroed in the paper before i thought of it, so he should get the credit. there is, ofis, of course, the question, we want to reward risk-taking in america. drug company investors take risks, thererisks, there is no question about it. the right amount of risk premium we want to pay investors and pharmaceutical enterprises, the amount that would give us the right flow, the desired flow renovation. that is what we would like to do. in real life that is hard to do. i was sort of thinking loosely, as i sometimes do. other people who take risks, firefighters, police, the military. they take enormous risk. what risk to be give them for that as a benchmark?

and then say, well, what do you need to do something for america, something good? these guys fight for us. you fight little bugs called bacteria or viruses. and if you look at it that way, you know, the risk premium we have is really quite good. that is what it looks like when it hits a roadmap. yes then people to go drive this thing and take this chance. you don't always need a boat or a jet or something to develop. let's reason this out. this guy should not be limited. healthcare has an opportunity cost, among them educating our kids.

finally, it is not uncommon to be with people,people, and i have been with these people, will tell you that if within the high prices of the drug industry they argue for more protection, cuts in social spending and lowering taxes. and they do that in one breath. you want everyone to have harmony. that will increase social spending. you'll need a phd to understand that. that brings to mind a theory that was developed, and astronomical theory of the strongest proof that there is intelligent life elsewhere in the universe is that it has never tried to

contact us. thank you very much. [applause] >> well, thank you for that wonderful presentation. i promised you an exceptional panel of speakers with a very diverse perspectives at the beginning of this command i hopei hope you feel that is what you got here today. not always a lot of agreement, but a lot of fun. anyhow, now is the time for questions. if you have aa question. you to fill out that blue card in your packet and passive forward. i will go ahead and throw out the 1st question. he has will it scale up? andrew, youandrew, you had more time to start the scaling up process.

why don't you least take a stab at that. >> it is a great question, and it is important. we don't do enough. there is a growing science of scale. i think the scale answer was provided in the opening talk by cms. our payment model alternative quality contract was written into the regulations that established the affordable organizations,organizations, and the goals and philosophy that has been established on accountable care and payment reform which is then causing the kind of delivery reform that we have seen in massachusetts and is being generated in florida as an example. i was just going back to

kaiser, there is an aspect of the kind of care we are promoting which is integrated and fragmented and involves physicians practicing more as a team, but i would like to think that also it will have some of the innovations that may not have been possible. >> two comments. first of all, thank you for going last. following him is not a fun thing. thank you for that. i believe what we are trying to do will scale because we try to have flexibility in our model. we asked for guidelines, not micromanagement. all of my markets are different. i cannot do it exactly the same way.

one of the problems is thinking that because it worked in california it will work the same in dc or somewhere else. customers of the reason that kaiser did not scale. customers were not willing to go to the model. now, i think we have different market conditions because if you think about consumer choice in the world most of us lived in your employer made the decision by selecting a health plan. there was a lot of angst among the employees. the market is becoming much more in it to have much more of an individual market command i think when individuals have the choice and see the cost scale between the different options, they are willing to make decisions about taking

a narrowera narrower set of choices or this particular set of providers because i understand the value trade-off equation is my expense. that is different than when your employer makes the choice for you. so there are different market conditions today which allows more of the kaiser type model to flourish again. >> one more question. thank you. i will ask another question. the question is, already talked about patient outcomes. the diabetics improving the cancer patients living longer?

>> we have outcomes, the things that we measure. diabetics are getting better in terms of the standard measures. we don't yet have mortality data on that. the ecology area is near where the measurement development is earlier. but i have no doubt that patients are healthier. >> we are seeing results headed in the right direction, but it is early. when i will say is, on the oncology side we created to cancer oncology aclu's for

the 1st of the type that were disease pacific. one of those was moffitt cancer center. we arecenter. we are trying to try patients to the very best facilities. if you think about how cancer is handled every hospital is trying to manage it, and get there are clear centers of excellence. we are trying to make sure we have an opportunity to drive to the center of excellence that handles the volume and has the expertise we are giving patients and members a chance to get care at the best facilities. >> here is a question. what is the role of provider competition or consolidation in the transition to value -based alternative payment models? many argue that they must march together to have a scale and resources and clinical immigration necessary to keep the

transition. is this accurate? >> i would say that integration we believe is necessary to provide the kind of care that a lot of us have talked about. thank you. but integration does not imply that it has to be ownership, shared ownership. you can have virtual integration. some are highest performing groups, smaller practices that are affiliated with one or two hospitals that are not owned practices. integration, we think, is a condition, but ownership is not. >> the one comment i would make is that we bought a multi- specialty practice just outside of tampa, florida for the highest quality practice in that area command the interesting part was there to main suitors were hospital systems.

philly doctors came and said comeau we would like you to begin this process because if we are bought by either hospital system we know we will have to compromise our approach to medicine and admit more patience than we think is right. we got in that makes because we want to learn, thought this was the right partner command they made a compelling case but how they would be compromised to permit the patient. are you getting that doctors best and most objective opinion? >> let's switch over. with all of the buzz in california how do you think this will affect the industry? will it ever pass?

>> transparency will help, but i'm not sure how much. drug company should be able to list why they think this is right. why is not how things work on a normal market. consumers decide whether it is appropriate. so transparency can help, but they already publish pharmacokinetic and make studies that are supposed to demonstrate if any drug comes along how much it reduces the length of stay and how much money the system saves from doing so, and typically show that the drug will cost more in terms

of the total cost of care. transparency alone is the issue. we need to have more competition. competition is what leads to pricing signals that matter. >> you want to comment? >> this issue of front -- price transparency, one should not oversell it. martin who work as an economist work at the ftc and was clear and pointing that out commanded is, if you have a noncompetitive market you still have very high prices, so you do need some form of competition,

and very often it does actually come in the form of made the product. there are a lot of people down. i have never been so down on it because they can in fact exert the competition which we have seen. the other problem is in the us there is no one price for anything. it varies by insurance company, products. what do you pay for colonoscopy? probably 50 prices.

if you look at the cost of making that drive, that's only part of it. and to make people understand what costs are. so i'm not sure what you actually get masking for costs information. all kinds of information. >> we have a reasonable amount of information.

>> do you see tools such as peer boss drug advocates. >> not really. if there is a perception, puerto rico perception, that is something larger companies pay attention to. you will not be super aggressive because i know that has policy and political qualifications.

these metrics can help but don't necessarily give you a real expression. they can compete and deliver prices. the uk has this agency called nice. they use these things so much that economists like to assess, does this truck cost more than 20,000 pounds sterling? if it doesn't we won't recommend reimbursement. a lot of people in

washington agencies and academics think that's beautiful. the problem is, it leads you to funny situations. about ten years ago nice was trying to figure out whether to reimburse. and because the drug was expensive they decided to reimburse for the drug if you are already blind in one eye but not if you could see from both of your eyes, the idea being that was not a biga big deal because you still have another i could see whereas if you only had one you would be totally blind and that would be bad. we won't pay for it to treat people who could see in both eyes. he can understand why the average person thought that was completely ridiculous.

it is critically important to have site in both your eyes. and so when a bunch of people are sitting around room making these decisions they are not always thinking about what the patient wants in that case the patient might have said it does not look like it, but, but i do want to see in them willing to pay for it. but consumers don't have the opportunity to deliver this person. >> here he comes. >> the public debate about spending on pharmaceuticals has been mostly this debate you have heard replicated on

regulation versus competition mobile what i say about the work being done is that it is bringing the voice of the commission to the debate which has been largely absent. by raising questions about the relationship between the price and efficacy of drugs is making an important contribution i think it will add a lot to the debate. >> i noticed the english you are using. how do you value this? he put a different price on this than a ratea rate

22,000 and a which is making 25,000 could command many economists would say, well,, well, which are says no value it as much. which is a mission to cover misuse of english. so ultimately you asked if you want to distributed on the basis of price and ability to pay? we could do this mode you like everyone to have access? and if he sent a letter to become the collective decision because then you are asking me much i'm willing to pay for someone whom i don't know i may not like if i did it this

treatment. to argue that the market can solve this doesn't make sense to me. the birds made that decision and i am sure that they relented. they repent when they see popular pressure, but that is a difficulty that was alluding to. we do not know what value to put on a quality adjusted life. the britts sort of do, but they relented under pressure we don't want to discuss it.

this congress won't even allow costs to be entered in cost effective analysis. congress hates cost-effectiveness analysis because it might implicitly put a value on human life. that is how shall we are. this is a larger issue than to say what i would be willing to pay for drug. it always turns out clearly in the case when you see the people who actually get this drug often on public programs are in jail and it becomes a collective decision. at some point our students will have to come to terms. i think that we can, forcan, for a couple of years, still sweep it under the rug. what you would not catch me doing is to say, yes, we should cover it command yes we should pay a high price commander should cut social

spending and lower taxes. that would not happen to me. i can guarantee it. >> i did want to comment on this as well, but i did not want you to explode waiting to get an answer out. let me make a couple of comments about pharmaceutical pricing. the margin on pharmaceuticals around the world is a fraction of what is the us. we should be asking a question about that. while we pay so much more endo we willing to fund the world innovation and research and development. i went on a delegation trip in minnesota the germany and the gentleman in charge of pharmaceutical purchasing germany asked us why you allow for pharmaceuticals to be advertised on television. has anyone seen the chart that shows us from the spending from before we haven't has ent veta afterwards?

and so you have to ask about efficacy. when we went direct to the consumer it exploded. we are one of the most nations in the world spending on pharma and get our outcomes and health levels are nowhere near other places. there are baseline questions that we need to ask about whether or not we are willing to fund the world on this and the fact that we restrict ourselves for negotiating is something that continues to amaze me, does not give more attention in the press,press, debate in washington dc. the largest purchaser does not get to negotiate the price. it is absurd. >> am tempted to end on that.

thank you. question is from the congressional office. only about 2 percent of people use them. will make is the last question. in massachusetts we are required to make that information available to our members command the key barrier has been you can tell someone the price of procedure. we talked about the price for colonoscopy, but could you tell them what they are price would be given their policy copayment. the website. the question is right.

the ticket still low, but it is starting to grow. >> i was completely agree with andrew command i cited that example in my comments. they are encouraging them. it is certainly available through our website. the take-up has not been a strong as we would like to be, but it is better than the national numbers. >> the base reason why computers don't use these tools is because they don't actually save any money if they use a less expensive hospital. by and large the economic incentive is not there is a part of what draws hospital economics. it does restrict competition and the ability of it

directs the highest quality lows caused care. so this is a huge problem that we must do more to address which involves two different lanes, antitrust and competition reducing barriers to entry and i ever side we have to give more opportunities to patients. in that way the insurance company has the incentive to make sure they are holding hospitals accountable. >> there is also a fallacy that if it costs more and is higher quality. we believe that the data does not bear that out of all. >> massachusetts publishes a cost report every year, and it turns out that the drift

has been toward more expensive facilities, and other words, they have these prices, but in fact rather than what you would expect people not know the prices in gravitate toward the cheaper, less costly facilities, it was the opposite. everything is going to ask both of you, are these binding prices, what was in the past? in other words, if i go to a dr. dr. that i thought was low-cost, my guaranteed to get low cost? in some senses it binding, or what am i looking at? >> today they are estimates within a range and based upon history. it is not an absolute contract, but gets

you within pretty close proximity. >> maybe the popularity will grow over time. >> let's make not the last word. i would like to thank our panelists. [applause] you guys have been a studying -- stunning audience. fill out your evaluation form and we would appreciate that. we would like to thank congressman crenshaw's office. i would like to thank allison myers.eg

kaplan on twitter. stay with c-span, c-span radio, and c-span.org for your best access to congress. next a discussion on isis foreign fighter recruitment and international efforts to counter violent extremism. experts examine how the middle east, europe, and u.s. are dealing with the problem and what the current strengths and weaknesses are for each continent. held by the brookings institution, that is an hour and a half. all right, everyone. welcome. my name is will mccants. i direct the project on u.s. relations with the islamic world here at brookings. today we are here to talk about counting violent extremism through early interventions program. brookings is doing this with the program on the partnership with extremism at george washington university. joining us today is lorenzo bodino to my right who directs

the program on extremism at george washington university. to his right is rashad ali who is a senior fellow at the institute for strategic dialogue. to my left is angela king, who is deputy director of life after hate. and to her left is daniel koehler, who is a fellow on the program of extremism at g.w. and founder and director of the german institute of radicalization and deradicalization studies in berl berlin. okay. so the countering violent extremism discussion has been going on for several year news. if the phrase sounds vague to you, it's also very vague inside the u.s. government and foreign governments. no one is quite sure what this thing means. i remember when i was working at the state department i asked another agency to give me a list of everything that had been justified to the congress as countering violent extremism

across all agencies of the u.s. government. pretty amazing. everything from building forward operating bases in afghanistan to english language programs for young mothers. essentially, it became a way for the government to protect their budgets and their programs. in an effort to become much more focused we are here today to talk about one slice of this that's often neglected, but i think honestly is the most valuable in the effort to stop or counter recruitment for terrorist organizations and that is early interventions. and so, i wanted to begin our program today by asking daniel koehler to tell us what early interventions are, how they differ from other programs, sayo

deradicalization of foreign fighters, what have you, and then we'll get to a more wide ranging discussion. daniel. >> thank you for the introduction. early intervention in countering violence extremism is an unusual term. usually when we look at other states in their counterterrorism policies we see there are three types of tools they usually use. the first one is prevention. so usually anything that is related to education, civil society. anything that tries to prevent people from ending up in radical groups can be seen as a tool. the second level is repression. containing an actual existing radical threat. law enforcement, anything that is related to core group, sting operations. then we see the third level which is called intervention. in most western european countries. so early intervention would mean

that we actually have someone who is in the process, in the early process, of the violent -- potentially violent radicalization process but has some connection to it, has some connection to a radical group, some connection to radical ideology, is on a path that's considered dangerous. so it is part of those tools where deradicalization programs, programs part of it. early intervention programs or tools usually focus on the social effect of the environment of those persons who are about to become a violent radical. so we know from terrorism studies, from criminology, that there's a phenomenon called leakage. that many persons leak some kind of sign directly or indirectly to family, colleagues, employer, anyone around them. and these persons are usually

the first ones to notice a change. to notice a potential threat and danger. and in most cases, the so-called gate keepers, the associate gate keepe keepers, do not reach out to the authorities, do not reach out to the police or anyone else because they feel a strong sense of loyalty, obligation to their friends and family members. they fear what might happen to them. maybe they're responsible for their son or daughter being put into jail for 20 years. so we need to figure out a way to give these family, friends, associates, gate keepers, tools, a third-party mentor they can turn to for assessment, for advice, for counseling, but also as some form of intermediary between authorities, between social services, health services to give them an understanding, an assessment, of why this is happening in the family or in their environment. and these early intervention

tools are really those who focus on friends, family, colleagues to give them a tool as early as possible to reach out and ask for help. later tools would be deradicalization programs for returning foreign fighters or those in prison, prison inmates, and these focus on individual levels. and early intervention levels to the effect of social tools. there are many out there. specialized trainings for teachers, for police officers, for community leaders. >> so, daniel, to my mind, these kind of programs make a lot of sense. because it's a small population that you're working with. they have already demonstrated they're interested in radical ideas, but generally, they have not committed any violent crimes

yet. so you're working very, very close to the problem. and the game is to try and make sure that these folks don't go over the line. over the line and commit a criminal act, particularly a violent criminal act. but legislatorenzolorenzo, thes haven't caught on in any many places, particularly here in the united states. when we talk about countering violent extremism it runs the gambit, but this is not really part of it. working in this space is usually, from my experience, often left to law enforcement, people that are already entertaining radical ideas that are thought to be a security risk and better to let law enforcement handle it than have these early interventions. give us the scene from europe. how does that compare with the united states? >> it's very different. if i fe first of all, let me open by

thank you for hosting us here. it's very good to have this conversation on the way we partner together on this and try to mainstream the debate that comes to the u.s., and experience that comes to europe and bringing people from the european experience. because some europe 15 countries have seen 10 or 15 years of this kind of intervention. everybody makes whatever they want out of it. and a lot of the attention in the u.s. has been focused on sort of the large target, the counter messaging, the counter narratives, the engagement of communities, which is also extremely important, and the europeans have done that kind of work. also the pro-integration work. it's very large for the europeans spend a lot of resources on it are very difficult to assess. very difficult to prove negativity. that what you're doing to stop people from radicalizing. i think what we have seen the last few years, the europeans have focused more on the one-on-one interventions for

some of the reasons that also daniel was mentioning in the u.s., as you correctly pointed out, that has not been the case. we've seen a lot of messages, more with the foreign partners or engagement of communities, which is basically what cve has been on the domestic front. >> you can explain what we mean by engagement of community, what that ends up looking like? >> yes, this is basically dhs, the fbi cells have been doing for a long time, which is building trust-based dialogues and relationships within communities. >> which communities? >> this is probably one of the points in contention and one of the most debated points is that cv is unfortunately limited for the most part to the muslim community. it's limited to targeting what was traditionally known as al qaeda inspired radicalization to

today what is isis radicalization. i think most people would agree that there should be nonetheless 99% of the resources devoted. i think in the u.s., we're limited basically -- we had been limited mostly to engagement. we're starting to see signs that they're working on one-on-one intervention. the very tailored interventions. which if successful are quite cost effective. and it's much easier to prove the effectiveness, not very easy, but easier, than some of the larger programs. and the european experience tells us that. so we have very different models that we'll talk about largely, depending on what the degree of involvement of government and a variety of other factors.

in the u.s. we're starting to talking about utilizing these tools. traditionally, we have seen a law enforcement-based approach. the traditional use of sound, very harsh law enforcement techniques. the fbi is basically in charge of investigation. if the european approach is on individuals who are clearly radicaliz radicalized, the european approach is to try to push, to pull back people into a pre-radicalization stage. the fbi approach has been in some cases, of course, to try to push the individual to have this kind of sting operations, have the radicalization process go further in a controlled setting with the fbi controlling everything and eventually arrest the individual, so two different philosophies. there's a growing realization in the states that that kind of tactic cannot be used all the time. it is very effective from a prosecution point of view, a

very high success rate in court, but it cannot always be used. we're seeing more and more minors attracted to isis ideology. and it's difficult to use for a variety of legal and ethical reasons to use sting operations when it comes to minors. the numbers are also very high. we hear from the fbi a couple weeks talk about 900 investigations, open nationwide. and individuals linked to syria and mostly to isis. that's a very big number unprecedented from the past. and it's difficult to tackle all of these cases with traditional law enforcement tools. i think that's something that the department of justice fully understands and is trying to explore some of the alternative tools. just to give you an idea, just this morning, we had meetings with the department of justice, with a particular working group, that is trying to find alternatives to prosecutions. we understand we cannot arrest our way out of this problem.

we decided it was useful to sort of introduce the tactics that they use in europe in order to advance the debate in the u.s. obviously not all the tactics used in europe can be transported and adopted here in the u.s., but there are a lot of ideas that with the proper caveats, with the proper ad adjustments, could be used here. >> daniel, i want to come back to you just to get a sense of what's going on in europe. in terms of early intervention programs, it's uneven across the continent. some countries embracing this. some not. which country would you hold out as the exemplar in holding that, and why? >> that's impossible to answer. you can't have a country like germany, for example, where they have almost 20 years of

experience in practical work against far right and extreme n neonazi groups. and they have -- at last count they have 12 to 15 specialized deradicalization programs in the area of countering violent extremism. you can't have a country like denmark where you have a very state focused police-run organization, where everything runs through the police. you can't have a country like sweden where they have one or two organizations doing that work in cooperation with the government. in countries like the u.k. where they have a strong complement or attendance -- >> depends on the political culture? >> absolutely. depends on whether or not ideology should power the program, and it's not that popular in denmark. not that popular in the u.k.

very strong in germany for example. i would say deradicalization or intervention can be ranked or classified according to three criteria. first of all, ideology. technically spoken, do we have a disengagement program without ideology, just a physical role change, getting someone out to do or to stop committing criminal acts versus deradicalization, really trying to get a dismantling of radical ideology. the second criteria is, is it state or non-state. is it run or organized by a government body like police, social services? or is it non-government based? and thirdly, is it active or passive? is it actively reaching out in prison groups or in germany, some have a list where the neo-nazis live. they just go there and knock on the door and ask if they want to leave the movement.

or are there passive programs, those wanting to get out? in europe, we've seen a very wide and broad array of different programs and constellations. i would argue the most promising the public/private partnerships, because usually, there are aspects that are being done more effectively by government bodies and on the other way around more effectively done by civil society organizations. so we have seen several attempts in germany or sweden or the u.k. where the government body started a core hotline or a core program incorporating civil society organizations that do the long-term counseling in a specified framework like ideology is part of the program or not, how long it should take. germany and denmark are definitely on the forefront of that. >> thank you very much. angela, i want to try and give people a sense of how one of

these programs really works practi practice. and you work at an institution that focuses on far right extremism. i'd like for you to talk about how an early intervention works with somebody who hasn't yet broken the law. and i as wonder if you could say a few thoughts about the role of ideology. not necessarily in terms of inspiring somebody, but when you're doing these kinds of interventions, do you really need to deal with the ideology, or do you focus on other things first? >> well, it's been a little slow going. we don't have as developed programs as europe right now. but with what we've done, we're out there doing interventions, doing counter messaging, doing cv. and for us, personally, we have not found that it's successful to immediately go in and aggressively attack ideology.

what we do is share very real, rue human -- raw human experience and connect on a different level.aw human experit on a different level. i think it's important to mention that we really have to be aware of what propels people into these movements. what's broken? you know, what is the underlying issue that made them feel they were messing -- missing out on something, that they needed to belong. a variety of factors that really push people into it. so when we go in and we talk to an individual, we have to have an understanding of what drove them there. that kind of gives us the foundation and the base that we work from. we draw on our experience. life after hate was founded and

is run by former violent extremists. so, instead of justifying the individual, instead of attacking the ideology head on, we ask them personal questions. you know, what has affected them in their lives. what is important to them. what are they interested in. what are their goals. and from there, we fall back on our own personal experience. and share that in a way that shows them that they are not alone, that they're not the only ones. that it is absolutely possible to disengage, to deradicalize. but at that point, they're not concerned with being deradicalized necessarily. and the referrals that we get come from a variety of places, whether it's a parent who is worried about a child that may be getting involved, some government referrals, human rights, and then we have people who contact us on their own and say, listen, i'm thinking about getting involved in this. i have a certain belief about a

certain thing, or i had this experience that's really pushing me in this direction, but i don't know. i'm not sure. can you talk to me about why i shouldn't, or what are the consequences or things like that? it's been in that way that we've been able to go out and start having successful interventions. and these are literally some of them -- people who by their own account are on the verge of committing acts of violence who are then prevented from doing so. >> are you doing any of these interventions purely online or is there always a real-world component? >> both. there have been cases where we have traveled and done face-to-face sit down interventions. we get contacted a lot by social media, by our website, and we definitely don't have the funds

to travel the country, you know, to do a personal face-to-face every time, but it is part of what we offer is one-on-one mentoring, whether it is phone calls, text messages, social media. and we, you know, get these individuals involved. for instance, we have a private group that consists of almost 30 former violent far right extremists, and these individuals, some of them have been disengaged and deradicalized for decades. some of them have just now come out within days or weeks or months, and we are using that network as a means of support, as a means of talking through issues, some of those issues that propelled them in in the first place, and it provides kind of the support that daniel talked about, whether it is a family or a community, that kind of support that is not there to

say, you're horrible because you believe these things. it's let me share my experience and how i got beyond that and finding that common ground. >> have you ever encountered anyone who was radicalized purely by what they had read? they're normal in every way, high functioning, but just consumed a lot of hate literature, or is there always something else underlying it? >> every case is different. some of the information that we're finding now is that not every person suffered trauma or abuse or has mental health issues or anything like that. some people came from perfectly stable, loving homes and for some reason felt a need to belong in that way. and it's different. in small percentage, were actually raised in an extremist

environment, that were taught violence. you know, there are individuals who were raised in a prejudiced household or they were taught racism literally as children. some will grow up and rebel against that, and others will grow up looking for a place and say this is it, this is what i already know, this was what i was taught. and there are individuals who will have maybe one experience that from that point on, pun intended, it literally colors their view of the world from that point on. and then there are some who will just read history or maybe think some things happened unfairly in history or one group is being represented more than another. we can't classify it all across the board. it really literally is case by case. >> thank you. so rashad, i want you to help give us the u.k. perspective on this, but i also want you to talk about the role of ideology. again because i think for many

people when you're thinking about early interventions, the first thing that would come to mind is you need to take on immediately the ideas that political radicals would espouse. have you found that to be the case in your experience when we're talking about islamist radicals, or is it like angela says, you're going to come at it obliquely by ly bly by looking the more deeper personality issues or societal issues? >> in our experiences, what you have is -- i look at four broad trends just to make it easy, although as you mentioned all the individual pathways are very different. there are those that have a political perspective. they have a political lens. they buy into a narrative, and they look at the world as very

similar to kind of what was old school leftist. you have the evil capitalist west, which is dominating the world. at its forefront is america and its allies which is suppressing the natural aspirations of most people in the world. and in this instance the conflict used on the communism and the west and now it is islam. they look at everything in the world through that. they look at israel/palestine through that ideological lens or political lens. they look at any conflict against iraq because of various different economic sociopolitical reasons, but actually it is a manifestation of another attempt of america to dominate over the middle east and suppress the rise of islam. so all of everything is viewed from that lens. you get others that are not

politicize as such, but they've had various different grievances in the sense that may have had questions which they faced in their life that related to their identity. they may be questioning their sense of belonging to wider society. they may have grievances related to racism and therefore the narrative appeals to them because of those things. they're approaching because they already feel they need something else. you then have others who have neither necessarily had a specific problematic set of grievanc grievancesé2=ç embracing a polil ideology, but embrace a form of religion that automatically separates them from everybody else. therefore they are separated from other muslims, who they see as not being true muslims or not

muslim enough. they are seen as puritanical. they have from there a religious inspiration for their political world view. the way they look at the world is nothing is truly representing the pure islam that should be re-enforced in society. the purism comes from a direct scripture. therefore they have this very theological political ideology. then you have the other trend of people that do actually just suffer various different ailments. they suffer various different mental health issues, and therefore those things have pushed them towards embracing a black and white perspective and therefore islamist ideologies are appealing in that context. most people will be a mix of those things. and therefore when tackling or

engaging with an individual, you need to be able to ascertain what are the push-pull factors. is it someone who has embraced theology which is telling them this is what the meaning of islam is, it is a political ideology that is aimed at ruling the world? if you're reading scripture in that way, it should be enforced and the government's role is to enforce that particular interpretation of scripture and there's only one view. then actually, i guess, the only way you can engage with that person is to break down the methodology and the way they're approaching scripture. if someone has a particular world view that is very, very narrow, then the only thing you can do is make them realize the complexities in the way that the world is made up. and this actually works in the u.k. in politics as well, i

guess. if you've been to kosvo or bosnia and you meet little tony blairs and bill clintons, because they were figures that were saviors for the people there, that isn't the case in the u.k. tony blair is not the most popular politician in the u.k. but at the end of the day once they start to see there's a complexity to their world view, then you can start to have more complexity and nuance in the way you understand people, society, and religion as well. and then you will have other people who actually they do need their grievances addressed. they do need their needs met. i guess that was the u.k. approach is multidisciplinary, is a multipro-pronged approach. we have the contest policy in the u.k., which is the broad counterterrorism measure, which

has what they call the four ps. protect. so as an example, there are boulders outside the u.s. embassy in london to stop cars driving into them. there's practical measures done in that respect. there is prepare. the other two areas of counterterrorism strategy are pursue, which is investigations, intelligence gathering, finding plots, disrupting them, arresting people and prosecuting them. and prevent. and prevent then is this area of what we've spoken about now, the individual kind of engaging with people who are either vulnerable towards radicalization or have become radicalized. that works in the prison space, the probation space, and primarily in the pre-criminal space, which is people that have been referred, whether it is by police, the public in general, or as an example in the cases

that we have -- as an example in the u.k. where there's hamas in communities that have said we have had your young individuals come into the mosque. he wants to know how he can fight jihad in syria. we don't how to deal with this. they will contact authorities and say, how do we deal with this? the authorities will spend someone who is appropriate to engage with that individual to make an analysis, a diagnosis, and then put a plan together. >> but there's been some criticism of the program as well, right? >> yes. oh, huge. >> why? >> i think this is important to look at. actually i think there's some very good ethical questions we need to ask. what we're talking about -- and the language is pre-criminal. we're talking about engaging with someone before they have gone on to commit a violent act. how do we determine that? what type of referral process? how do we know this is the case?

which is a reasonable kind of concern to have. the second, i guess, is the broader moral question that when engaging in deradicalization, especially when somebody has a theological foundation, what you're going to do -- and there are a number of different approaches, but you're going to engage with their religious proclivitie proclivities. the question of a secular state -- in reality we are a succe secular state. our policies are founded on secular values. then that comes down to the logic behind early intervention. actually if you have an individual who is starting to experiment with soft drugs, be engaged with them because they may lead to harder drugs. if you have a young kid who is truant from school and we've

seen them around and they're getting involved with gangs, do we have engagement and an early intervention? we should have an intervention if we have a kid who is mouthing off about how great isis is. whatever it may be, that actually may require some form of intervention. and the other side of that, i think, is more the problematic criticism. so as i mentioned, there's a difference in pursue, which is the investigative side, and prevent, which the strand of channel intervention is one side of prevent. it actually has nothing to do with the investigation side, has nothing to do with the surveillance side, has nothing to do with the intelligence gathering, but there is a lobby called protect and prevent. the state, which is inherently

evil, i get that, therefore what we should do is monitor everything state does, which is good. but then it becomes the state must be using this for intelligence gathering. it must be spying. it must be targeting the muslim community and therefore all of these things come into this anti-prevent narrative. some of those things can be easily dismissed. 25% roughly of individual referrals have nothing to do with islamists, but actually to do with right-wing extremists that are planning plots. the overriding majority as mentioned there may not necessarily be a theological engagement. many referrals come from the mu muslim community and out. and you have to remember people also have political -- it's not

surprising that an organization, which i will mention, which is previously supported anwar al awlaki. they're al qaeda apologists. therefo therefore, you have to understand there are groups that buy into the islamist narrative. on the whole, i think a lot of the criticism is based on propaganda rather than actual analysis. >> daniel, i want to turn back to you. the counterterrorism part of my brain hears about early interventions and says, yeah, that makes a lot of sense. you're focused very narrowly on

people who may become a problem. they've demonstrated. they may like the propaganda of a violent group. that's the one you really want to focus on. but then the american part of my brain speaks up and says, well, wait a minute, these folks are entitled to free speech like anyone else. this isn't exactly criminalizing speech, but it seems to get right up on the line, if not over it. i'm trying to figure out how to strike this balance, and i gather from your comments that a lot of it has to do with the unique political culture in each country. if we were in germany, they would have a different answer versus in the united states. but how do we find that line? how do we keep this focused on a very narrow problem without running afoul of the proud tradition of free speech that we

all value in a liberal society? >> i think that is the core question of how you make deradicalization programs work. deradicalization has a built-in moral problem. it works usually -- it is supposed to work in a democratic pluralistic society, but we know on the other side that starting when something criminal happens, a criminal act or in the prison system, it is much more ineffective. it is much more expensive, and there is a process leading to that criminal act, leading to that violence that is dangerous, inherently dangerous, to democratic society because it embraces an ideology that is actively attacking and sub versing and trying to destroy the democratic pluralistic society. neo-nazis in germany have always

tried to hide under that freedom of speech. even though the german freedom of speech is much more restrictive than in the u.s., obviously for traditional reasons. i would say that this problem, to figure out this problem, when an inherently dangerous process starts and balancing it against what is morally acceptable in terms of a program is essentially a question of how do you structure that program and who finances the program. for example, i get the fact -- and i'm very critical about government-run active programs who try to change a political religious world view, for example, in prison. and there are programs who are more or less coercive in prison. don't expect to get any special or beneficial treatment or anything like that.

so then on the other hand, there are non-governmental programs that can have close associations with the government, but they have an own political fill l philosophy, so people come to us when they need help and we are transparent. ngos say we have an own version of how democracy goes. if you come to us for help, this is what we expect in turn. so in these instances, deradicalization can be morally completely acceptable in a democratic pluralistic society because there are many ngos, people are free to choose, they can go to another ngo, so i think it should be somewhere in the middle. i have worked with the new dutch program and they're currently building a new deradicalization strategy and program, and they have set out a very interesting

framework. they have set out the framework where they work and how they work in close cooperation with ngos, and they are very firm and strong on their own political philosophy. intervening with people in prison or shortly before doing something is too ineffective and too expensive. we need to figure out, especially in northern america, what is the point where we figure out that it's not acceptable. this kind of ideology, this embracement, is kind of propaganda spreading is trying to destroy the society that you're living in, that protects you. deradicalization programs when they are private/public partnerships can benefit. what they're doing now is they're directly aiming at

destroying these central rights. just ask yourself the question. would any person who is not part of your group, racial group or religious group, have different or the same rights, or how would you treat them? from today or tomorrow, would you force them to leave the country? would you put them in camps? would you grant themless lesser rights of speech? would they have to pay an extra tax? would they be killed right away? these indicators are essential to figure out what you're going in that. >> thank you, daniel. i hear daniel. you know, it's -- i can feel the response in the audience from americans. it's a very european perspective. >> guilty as charged. >> yeah. and in this country we let an

awful lot of stuff fly. and so i wonder again, rashad, how does the united states, which has barely put its toe in the water of these sort of interventions, how does it find that line? >> well, i think actually i was going to comment on a couple of things. in the u.k., it's a voluntary process, so there cannot be any coercive approach towards individuals. either they choose to engage or they don't. and if they choose to engage, then it is a voluntary process of them dealing with the whole deradicalization or prevention strategies. so in that sense it's something that the state supports, lends its support to it. >> if they are radicalized, why would they engage? >> why do radicals engage? i mean, i don't know if i should make any comments. it's very difficult for me to talk about trump or anything. >> let loose.

>> why do people put themselves forward because they fundamentally they have something to offer no matter how utterly ridiculous it may be? it's either a benevolent or nationalistic motive. they want to persuade the rest of society around them that their radical world views is dramatically better for the u.s. or for their communities or for muslim communities or for british muslims. secondly, with a lot of individuals, they obviously have doubts about what they're doing as well. so human beings aren't black and white. they generally have a set of complexities that push them towards engaging with other people. the reason you have leakage is people also want an intervention. it's the same reason why people will talk about suicide because

they are feeling -- and when they do, we know we should take it seriously, but actually they are reaching out for help as well. and so there's those factors -- in almost all cases, you have a high rate of people who want to engage with you. now, i don't think that is a problem because we do similar early interventions. the problem really here is because it seems like we're controlling the political persuasion of people or the religious proclivities of people, and that is really where we have a problem because we do believe in free speech. in that sense, i believe there are some very reasonable criticisms to be made of what's called the counter extremism policy in the u.k. or in the u.s. because they're talking about disruption of people who have extreme views, which are illegal, people who are anti-democratic, or anti-liberal, or banning

organizations that undermine pluralism, democracy, and human rights. that is something that is absolutely impossible in the u.s. context, thankfully. it is quite a horrific conservative regressive idea. on the other side of that, i think there is a moral imperative of civil society as a whole to stand up and do something about this. and so what really you have with the counterextremism measures is a partnership between government, you mentioned this earlier, a partnership between government and civil societies. we as civil society can engage in the deradicalization process in countering these arguments, and government's role may be to support or facilitate that. actually, the argument put out on an economic basis alone is saying we should actually do

something. on a social moral perspective we can't sit back and do nothing about this. to explain what i mean, we've had a huge number of migrants coming out of syria and iraq. i think europe is talking about 2 million people, between a million and 2 million people at european borders. are we talking extremists in europe? on the one hand, we have a moral responsibility to not send terrorists abroad, which is essentially what we've been doing and hence my point about al awlaki earlier. so we have a responsibility to do something in a policy space as well. >> thank you. angela, i'm still trying to find this line or this balance between public and private. your deputy director of a

private ngo. if you can, just -- and you can talk about in the abstract if you like, but what's the right relationship between an ngo that does these early interventions and the government? or should there not be one at all? >> are you trying to get me in trouble? >> not at all. >> well, from our perspective, we all can play a part in interventions and disengagement, but we have to define the roles, what's needed, and who's best suited for each different aspect. so for instance, the easiest example i can give is when i was an adolescent and i was becoming radicalized, i was getting involved, i was headed towards violence, i'm always asked what

could have stopped you, what could have been done, what kind of a person could have approached, what would you have heard that could have changed your mind? and i thought about this for years and i know with the kind of teenager that i was it would have taken someone with real-life experience that actually understood what i felt, what i was going through, the obstacles that i faced, the issues that i dealt with. so i think when we go out and look at these relationships, there has to be support. there have to be people who can go out and act. there have to be all these different aspects of it. this maybe on popular and i apologize if it is. i do not believe that relationship between ngos like mine and say law enforcement should in any way be intelligence.

it should not be telling on people, giving up information. if we are to truly go in there and do this work, we have to create communities of trust. another example i can give. when we get feedback -- for instance, we recently produced four psas investments. we targeted individuals in the far right in the u.s. we expected a negative response, but in essence what we're doing out there is saying, number one, we've been there. so behind closed doors when you're feeling like this really isn't what you thought it was going to be, you know, there are things that you just didn't understand, those feelings of guilt or shame or doubt are creeping in, we get a response from some individuals that is so

intense, so filled with rage, and we'll hear things like you're the worst traitors of all because you knew the truth and you walked away. those are the kind of responses that are telling us we're striking nerves. we're doing a good job because those individuals that are voicing that, they are probably the ones that are having those doubts. they're the ones entertaining them and they feel ashamed. they think they're going to get caught. they don't know what to do. so when we look at things like that and start to build these relationships between government, between ngos and people on the ground, we need to keep this in mind. i'm going to be a lot more successful going out and doing some intervention work, some cve, because i'm a credible voice. because i've been there. and especially with the far right in the u.s., we're dealing with people that cling to conspiracy theories, paranoia, they already don't trust the

government or law enforcement. so we need to be very clear about those lines in the relationship there. so there's always room for collaboration. we all have a part to play. we just need to define those roles very carefully. >> thank you. daniel, you had a point you want to make. >> i want to comment on this problematic or highly debated question of the relationship between an intervention program, the clients and authorities, security agencies. i know that there are programs run by intelligence agencies who just use that for hard intelligence gathering, names, addresses, group structures, anything like that, which actually hurts the idea of intervention but also hurts the families. it puts the family at risk or the social environment at risk and it's accepting risk to burn them by simply getting a couple of names. but i'm very positive about counterterrorism acquisition programs.

many people think, i suspect in the u.s., that it is seen as a weird, soft approach to something that should be handled by the pros, by agents, fbi, intelligence. so if you look at how do de-radicalization programs operate, many include former military, they know what they're doing. they do risk assessment in an area that overlaps. you can identify concrete aspects like reduce manpower of a terrorist group. you pull out human skills and knowledge out of that group. the group needs to refill that gap. needs to invest resources in recruitment and train other people within the hierarchy and it's proven that this organizational cost that you put onto these groups by getting people out can even cause a complete collapse of a terrorist

group or radical cell. plus, what i would call soft intelligence gathering. i'm not talking about individual names and addresses but for example you locate where a new recruiter is active or a new group is active or a new topic of recruitment is active or a new style of jihadism has emerged. obviously that's something that you can pass onto the authorities. you gain a lot, especially knowledge about radicalization process, about connections that you can use in training and skill building for probation staff and police and for teachers that is very, very influential and very important, and you make the work of law enforcement much easier and much more effective by providing that additional angle. working with families and people who want to get out themselves closes the gap of that network of counterterrorism network and actually it helps to remove a blindfold of that area, that

social area where radicalization occurs and you can actually help the police to become much more effective. >> thank you. i want to open it up for questions. before i do, i want to ask lorenzo a final one. i'm in a think tank. you're in a think tank. we have to think in our tanks about what kind of policies come out of this stuff. you and i have been thinking a lot about why it is we don't have intervention programs in the united states for political radicalism. even angela's program, you were telling me, is unique in this country. i know working on jihadism there's the word organization in d.c. and some others that work on it, but it's still in an early stage and there hasn't been a lot of support from the u.s. government for these kind of efforts. i got my own ideas as to why.

i'm curious why you think there hasn't been a groundswell in the government for these kind of programs? >> that's a very good question. i think there's a combination of overlapping reasons. there's not really even a debate into building some kind of intervention when it comes to the right wing extremism. the debate is just on jihadist threat. something that again we can discuss. we have seen a lot of talk but in reality very little resources, very little action. i think there's a variety of reasons. one is the fact that at the end of the day the threat has not been as big -- the domestic side at least -- as in european countries. we have never seen the sense of urgency that exists in european countries. if at the end of the day you look at which european countries are most active, those are touched by some sort of an attack.

>> is it worth doing? >> i would argue yes some small scale intervention. i'm saying that has somewhat prevented the initial trigger, the dutch have been very active. the brits very active. it's after a trigger event. we had some of those in the u.s. boston is a pilot city now when it comes to cv. it is justified. the numbers here are so much smaller than most european countries so there's not a sense of urgency and add to that the tools law enforcement has here is more powerful than most european countries. at the end of the day the fbi can do its nice sting operations which no european law enforcement agency can do and it's a very safe space. now, we can talk about the problems, the ethical problems, the community engagement issues

that go with that. if you are the fbi, it's a very nice tool to have. it's very effective from that point of view. i think a lot of it has to do -- i'm acknowledging somebody that's written a lot about this issue which is jerry. the fbi is an organization that's very much based on numbers. on effectiveness. if you run an fbi field office somewhere, you make a good name for yourself, you make a career based on the number of people you prosecute and not the number of people you prevented from radicalizing. i think the fact that the fbi has such a big role and the fbi has this sort of mentality -- i'm not saying that in a negative way -- prevents a lot of discourse to go forward. >> would you also say it's political culture as well? >> absolutely. >> reading the channel document which channels the program that intervenes in the u.k., that document is a sober document. they talk about risk and what happens if someone goes through the program and carries out an

act and who gets the blame and what happens. my sense here in addition to everything you say is that politically also no one wants to put their name on this kind of program because they're terrified that one person goes through the program carries out an attack and the program is done and the person's career is done. you signed off on it. >> that's the reality in which we are now which is somewhat problematic. we are seeing that the fbi and more in general the counterterrorism community understands that they need to use these kind of tools and they are occasionally sporadically doing it but without clear guidelines. we see cases when it comes to minors where we see people with mental issues as the case in denver where the fbi or other agents, mostly the fbi, does this kind of intervention but they do not really have guidelines on how to do that and the legal part is one of the big ones.

it's one of the things to some degree we've been advocating as a center. do it but do it right. do it with the right training. do it with the right knowledge. do it with the right partners. do it with the right legal guidelines. that goes for the fbi but also goes for people in the community that want to help. it's a concern that we hear from people in the community. they do want to help without clear guidelines they are afraid that engaging with somebody was an extremism and might become a terrorist and will be charged with material support of terrorism which potentially is something that might happen. so to work in that space where most people recognize the next step for u.s. counterterrorism policies domestically it needs to happen but it needs to happen with clear guidelines coming from the top. that's what we're not seeing. >> the top means department of justice? >> that's one of the other problems we see. there's a lot of entities that are somewhat fighting on who should be running that space. the whole alphabet soup of

agencies there, everybody sort of claiming one part of the portfolio. dhs, fbi, we do not have a leading agency there although some things are moving there. but those -- then you have the federal, state, and local level. all those issues come together and really nobody takes charge of this. >> okay. let me open it up to the audience now. let's see. down front here, please. >> thanks very much. a fascinating discussion. i write "the mitchell report." i want to focus if i can specifically on the jihadi and isis sort of cluster and pose two questions if i can. one is -- as opposed to far right radicals or neo-nazis, et cetera.

some of us have attended sessions in this very room on the role of messaging and counter-narratives and i would be interested to know particularly as i listen to what angela had to say about how you would do this successfully, i'm interested to know whether and to what extent you think messaging and counter-narratives can have some success in this process of keeping people from stepping over the edge. and then second, if it's appropriate or if there's time, i'm interested to know how you evaluate the considerable work that the saudis do on this issue and how you evaluate that.

>> okay. so we have a question about the ethicacy of counter-messaging and then about the saudis. >> obviously there is a long tradition of de-radicalization intervention programs int3+ñf middle east and south asia and saudi arabia is leading that. i think they were classified as an active government, highly ideological program. what they try to do with a lot of money and with a lot of effort to replace jihadism with wahhabism. nothing of what they do could work in the western country to be clear. what they do is they have very strong sense of what is necessary in a practical

dimension of de-radicalization. getting financial support for moving out and getting a home and they buy these people a car and they finance the families to come in and meet them in prison so the practical dimension is very good and i think there's no western country who would put so much resources into that kind of work. in terms of evaluating it, there's no de-radicalization program on that planet who would not claim 100% success rate or at least a high success rate. the saudi program is no different. they say they have a 95% success rate. it was just a year or two years ago where they arrested an 88-person al qaeda cell in saudi arabia. about 50 of the persons were graduates from the program. there were a number of terrorist plots led by graduates from the program. there's been no scientific evaluation of the program whatsoever. the only information that comes is from people who run it or

finance it or say 95% success rate. they are good and they go out. this touches the issue of the program. i'm critical and skeptical. i'm convinced that de-radicalization can be evaluated and should be evaluated and can be effective. there are a lot of questions like data access, the relationship of the researcher and the program, who financed it, who has interest in positive or negative evaluation, it's highly complex and highly political. i think the saudi program is so popular in the muslim majority world because it's very outspoken in terms of we teach them the right form of islam. we sit down and debate them out of it. western countries to be honest i've never seen that work in practice when jihadi kids are in prison and you send in imam and say you listen and this is islam how it should be, they have no reason to listen. first of all, you're not a real

muslim. why should i listen to you? you're government paid westernized muslim or government muslim so i do not listen. they simply say it because they want to get out of prison earlier. it's an interesting program. it should definitely be taken into account what can be done practically in terms of classes and financial support and sustainability. the ideological component, i'm very critical of that. i know what's been written in the media and what's been written in some very rare studies about the program. there needs to be a real evaluation. >> on the question of counter-messaging, is it worthwhile to do given that isis has gone out of its way to anger most muslims in the world. you don't light a fellow sunni muslim on fire unless you intend to put your finger in the eye of every muslim. we don't message as a government

against neo-naziism. it's just mainstream culture decided it's a vile ideology. should we do counter-messaging? >> it fits into the last question. the saudi program is essentially saying you should only engage in acts of terrorism when we tell you to do so.mzg otherwise, it's just wrong. that's the substance of that kind of theology. it's what it boils back down to. that obviously will be beset with all sorts of issues. there's the credibility thing that you mentioned that actually when you engage with somebody in prison that you are acting on behalf of state and if they already deny the state, you're starting on a negative already. having said that, i actually -- my experience has been very different in the u.k. we looked at over 100 cases over the last six or seven years and

actually in that space the overriding majority that we've looked at where there has been a theological or ideological component in the de-radicalization has taken place and there's continuous engagement since. so in my experience actually, it can be done. i just don't believe the religious specific perspective of the saudis is necessarily the most appropriate way to do that. looking across the world at indonesia, morocco, egypt, have various different takes on it. in indonesia you do the wraparound thing where they do the whole ideological dimension, theology and taking care of the individual and their family, et cetera, on cases where they convict terrorists. a lot we can learn from in that respect. this is why i think messaging if it's calibrated appropriately and has the right messenger, it

can be effective. there are various different groupings of people if you like. you have the blood thirsty neo-sociopath that wants to join isis because they burned this jordanian pilot alive. because as you explain in your book they are successful -- sorry. because actually they are sociopaths attracted to the savagery. the other thing you mention that's really interesting is the management. a book about how you need to be savage in order to win and that's what modern jihadism should be and he explains tactics around it. one of the things you mention is that actually he talks about random killing of women and children and civilians.

he explains that this is in direct opposition of a saying of killing women and children. actually coming from an academic voice which is not political which is someone just looking at it, would resonate with a lot of the young people i speak to. it's not muslim but academic who is more interested in politics but is just pointing out your religion is not blood thirsty in that sense and therefore that actually does have a resonance with people. i say that because i engage with young individuals from various different spectrums. in that sense messaging if it's calibrated appropriately from different messengers so, yes, the u.s. state may not be the most credible messenger toward jihadi.

it's fairly reasonable to say. then there will be academic voices like yourself and muslim voices and there will be theological voices and then people at various levels of persuasion. some buy into politics. no matter how much you dislike a particular government, it never justified a terrorist act. then that messaging will have that impact. it depends really. that's not a great answer of calibrating and getting the right messenger will determine how effective the messaging it. i firmly believe it can be effective. >> gentleman in the brown jacket here in the middle. yeah. >> thank you. i'm a retired analyst but worked for among other places a unit in the state department called counterterrorism communication center. the strategy that we worked on

at that time was to mobilize voices in the islamic community to do the counter-messaging that we've been talking about not from the u.s. government but to mobilize people in islamic community, which would be perhaps more acceptable voices to the target audience that we're talking about. and i think that's still a valid approach. i would be interested in further comments on that. >> if i could put a wrinkle on that as well and angela and lorenzo, please jump in. what happens when the communities don't radicalize? like we're talking about far right extremism. there's not been a big movement to push back against that. you were saying that yours is one of the first in the united states to push back against that.

does the government need to fill that space? does it need to quietly encourage nongovernmental organizations to do it or should it just sit back and wait to see what happens? >> from my perspective, i know the numbers aren't great, but i don't think we can afford to wait to see what happens. i'll give an example for that. it could be something as simple as a community being empowered with knowledge. what do we do if we see x, y and z and for that example i'll use the charleston shooting. that individual publicly stated to several people that he was going to go out and commit acts of violence. if that community was empowered, if they weren't afraid or think i don't want to call the police, who do i go to? i don't know if it's a credible

threat. and with that example i will say that we can't afford not to do something. we can't afford to say the numbers aren't that big so we can just let it go. the numbers are getting bigger. certainly not on the scale, you know, with other things that we've seen, but there's a problem. >> when you say we, you mean private citizens need to mobilize to set up more ngos like yours? >> well, i'm into all kinds of stuff. i would say we as a community. all of us who are engaged in this kind of work whether it's on the academic side, whether it's on intervention, cve, counter-narratives, policy, that's what i mean by all of us. >> needs to take extremism more seriously.

>> there is something that you can avoid that happened in britain and to a large extent across different european countries. the failure in britain was that civil society didn't stand up against the phenomenon of radical extremism. i mean, i think that reaction is terrible but the reaction is because civil society has failed to challenge the ideology. what do i mean by that? i mean we have as an example the leader of the labor party, the leader of the opposition in the u.k., the main opposition in the

u.k. who is someone that's invited someone to come into parliament in the u.k. who describes hezbollah as his friends. these are blood thirsty organizations that do a lot of good social work but they have terrorist fringes as part of their makeup. yet civil society has allowed them to be incubated within parts of mainstream society. this is one area where we can benefit and heed the words of john which is don't embrace your values in historic tradition. you forget why you fought for separation of powers. why you decided there should be no religious test in your constitution. there's a reason and rationale why you decided that when you formed your constitution.

essentially the values underpin intellectually you have to stand up for and this is why we see regressive measures and i think that comes in both with your muslim communities and everybody, muslim or not, must share that stake in standing up for the american dream or whatever your particular aspirations and values of life, liberty and fruit of the loom. >> fruit of the loom. what can i say? i think what he's saying is fitting to the u.k. dynamics but doesn't apply to the u.s. a lot of what we discuss is very country specific. you said it works in saudi but not in other countries. here in the u.s. we do not have a problem of communities radicalizing. we have a problem of scattered individuals. occasionally there's more clusters of five individuals, similar to an online community, but it's a completely different dynamic.

the counter-messaging, the working with communities, great stuff. it can't hurt but in some cases if not done properly it can actually hurt. for the most part we're talking about individuals here and there who are radicalizing. we're communities but are generally rejecting radical messages unlike important part of the british community. it's a very different dynamic here. some of the big role of the state, social engineering, the needs for the communities to really speak out, i'm not saying it would hurt in the u.s. but not necessarily needed. it's not a matter of communities. maybe there's something to be said about the part of the community in minneapolis but it's generally few of the individuals not part of the community. shameful in pitching our stuff but a study we did on isis in

america looking at the individuals indicted in the u.s. for links to isis since 2014. 40% of them are converts. don't really belong to communities. most of them are new converts that people for a variety of reasons but in most cases belong to the fourth category. people with some weird personal issues radicalize. outreach to communities doesn't do much in that case. a lot of this stuff doesn't really apply to the u.s. >> thank you. let me gather a few questions. gentleman in the baseball cap in the back. >> thank you very much for an interesting discussion. my name is ken. my work was with addicts as a therapist. i wanted to see if there was some comparison to addiction treatment.

people need information to self-diagnose. if they don't have a self-diagnosis, they really don't take steps. part of that is a measure of soul sickness. i've seen that even in guys who were in combat who were working with radical organizations and even people in the idf got disgusted with what they were doing and had to make a journey but they also needed to have individuals around them that would serve as elders, a sponsor in aa or in recovery but perhaps it would be someone who had charisma of going through this difficult journey back. i wonder if you might want to talk about that comparison if that holds valid. >> let me gather a few more questions. there was one in the back. nope. her hand is not going up. there it is. >> hello. i would love to hear the panel's

view on some of our quote/unquote allies approach to countering violent terrorists. for example, egypt and turkey and israel. >> thank you. let's take another. down here in front, please. >> thank you very much for a fascinating discussion. i'm curious if any of your groups or you know of other groups that might actually have become a target for some of these violent extremists? when you think of the example that you end up dismembering a cell, it's just a very soft way of destroying it, right? ultimately you are an enemy. i'm curious if that's something that's of concern. >> thank you very much.

let's take those questions. just to remind you, we have a question about similarities -- what do do you with people who have a problem but aren't willing to take the next step? we have a question about the way states in the middle east handle radicalization with egypt, turkey and israel. and then finally about whether any of you or if you heard of anyone being a target of doing this re-radicalization work. >> gosh. i think lots of people get involved and you end up becoming targets in the u.k. or have threats. so there is that risk for people.

i'm loath to figure this out. i think it's normal. we tend to live in liberal bubbles. the rest of the world isn't really like that. i think kind of comes to my -- the last question, some of the h horrific practices of the egyptian government we should stay away from in terms of suppressing through violent means, not even terrorists but political radicals, people who we may not see eye to eye with and we think their ideas are horrific, but we shouldn't be supporting the suppression and repression of the muslim broadhobroa brotherhood. israel, how long you have got? i'm going to avoid the israel.

turkey as well has become more and more authoritarian. that is a problem. >> at a conference i'm at, colleagues from turkey was about deradicalization. i talked about this intervention, ideology. and then turkish said, we put them in jail and they are de- d de-radicalized. neutralizing a threat. i know that they have changed a little bit in their community outreach project. they have a lot stronger community policing aspect where police officers would go uninvited and hang out gifts and be present and be nice and be open. they don't have de-radicalization programs.

the question of the threat against people who are engaging in that war. you have to differentiate between those that naturally get attacked and threatened by former groups because they're a threat to these groups and those who are professionals and come from another background. and it's how you frame these kind of narratives. to give you another example of counter-narrative intervention, i'm leading a group together with inspirational group called mothers for life, a group of mothers from nine countries across the globe who all have lost their sons and daughters. most of them have been killed in syria and iraq. the mothers wrote an open letter to islamic state and posted on various social media sites and you can find out about that online. the idea was next to fathers, mothers are in a central position to challenge beliefs

and ideologies because there's a famous saying of the prophet so mother irregardless of the faith or ethnic background language, she's the mother and has something to say about that. we wrote that letter and used jihadi terms and described how these mothers felt after their sons and daughters were killed without mothers having a chance to intervene against that and would you guess how long it took for islamic state to officially respond to that? 3 1/2 hours. after 3 1/2 hours an official twitter account tried to scorn the message. after a couple days when the letter was translated into eight, nine, ten languages they shift their response in posting jihadi recruitment saying you might have a point there but it's something different. you misunderstood what we

actually do and here are videos showing that we just workout and training and it's nice. the response shifted from ridiculing and rejecting it to acknowledging parts of the message and trying to turn it around. none of these mothers were directly threatened after that even me as the family counselor or as an expert in that i was never directly threatened. what you said, of course it's dismembering these groups and dismembering the ideology and empowering those who are really dangerous to these groups by their simple biography and their simple natural being. i think it can be done in a way that these cells don't even recognize what is happening. it's simply getting more difficult to recruit. it's getting more difficult to hold your members in the cell and suddenly you are engaged in an internal controversy or argument with your own members why the person left and why are

these mothers saying we shouldn't go to syria and we've been told the mothers are so important. you create much more noise and slur within these groups that potentially creates doubt and fallout from all of the other sites which you can use again and all that stuff. >> we have time for two more very quick questions if anyone has a burning question. good. all right. we answered everyone's questions. lorenzo, a final one for you. and that is if you had one recommendation to make to the u.s. government thinking through this stuff, you've looked at this issue in europe. you've looked at in the united states. what would that one suggestion be? >> easy question to answer. a couple things to expand a bit.

one, resources. the bottom line is there's a lot of talk about cv in america resources. at the same time we do not need a massive large scale program like saudis or europeans. the problems are very limited number wise so we've been arguing at the center is targeted intervention accompanied by engagement which is useful not just from a security point of view and securitizing the relationship with communities. keep engagement but at the same time start with intervention programs with partnerships with community, open up the space for civil society and ngos to be partners. obviously with clear guidelines for everybody and i think it's something that can be done relatively on the cheap based on pre-existing structures and i think would allow law enforcement to zero in on the problematic cases and not spend resources on the 15 year old who is on facebook googling killing

shias just because it's a phase and allows the fbi to zero in. it's a matter of resources put in the right way. it's not a matter of creating massive structures. >> thank you very much. and join me, please, in thanking our panel today. [ applause ] on the next washington journal, s sulma arias. then former homeland security secretary tom ridge looks at new threats to the u.s., including threats to cyber ware and the electrical grid. after that, dr. thomas frieden discusses a reported 25% increase in multi-state food borne outbreaks in the past few years. your phone calls, facebook

comments and tweets. washington journal live at 7:00 a.m. eastern on c-span. two things are different. we have a justice system that does not -- these trials were not held according to what we would consider modern law. hearsay is acceptable. innocent until proven guilty had not yet been -- was not in place. no one has a defense -- there were no lawyers, by the way, i should say at the time. the courtroom is an extremely unruly place. that's one piece of it. we don't happen to believe in witchcraft or prosecute that today. >> sunday, stacie shifts talks about her book on the salem witch trials and the scope and affect the accusations and trials had on the massachusetts community. >> the interesting part of about the acquisitions, especially given the way we think of salem

is that wealthy merchant were accused, sea captains, homeless 5-year-old girls were accused to be witches. this is not an where all the victims are female. we have five male victims, including a minister. we hang them. so in addition to the speed, there was so much encrusted myth and misunderstanding here that i felt it was important to dispel. >> sunday night at 8:00 eastern at pacific on c-span's q and a. a democrat and republican who were sentenced to prison for minor crimes now discuss their experiences and why they are calling for criminal justice reform. they spoke at the american enterprise inststu institute for and 20 minutes.

ladies and gentlemen, thank you for coming. i am tim carney. i'm a columnist at the washington examiner. i think you have seen erupt around the country, especially in the last year, a discussion on criminal justice reform, on over-criminalization, on all sorts of things. we're going to focus today on a specific aspect of that. let me just -- my thoughts on part of why i picked this. this is about prison specifically. i have got libertarian leanings. i think too many things are illegal. i am a catholic. i think justice and mercy need to be played up. on the other hand, i don't know and i don't think necessarily we'll get into today a question of are we maybe locking up all the millions of people we lock up makes our country safer? that's a tricky question to debate. we have lots of opinions on that. my questions once we put people in prison, are we doing anything to help them, or are we just ruining lives? so when you -- having prison sentences serves a deterrent effect. there is some good there. it keeps dangerous criminals off the streets, so there is some

good there. we call these correctional facilities. are they doing anything to krekd, or are they just making things worse? once people are in prison, are they being harmed? are they -- or are we treating them in a way that will benefit society or hurt society? i think we know the answer to that question, maybe. can we change anything going forward? what i did to discuss this is asked two guys who i know who i dealt with in their -- in their lives. i write about lobbying and politics. so i brought in a former lobbyist and a former politician. on my right is kevin ring, a lawyer and former republican congressional aide. in fact, he was executive director of the republican study committee. he passed through the revolving door and became a lobbyist in 1999. he wrote a book which was big reading in my house with my brother when he was in law school. it was scalia's dissent. i guess you compiled the book. it was an excellent book.

if you're feeling angry and want good things to get your bile up and running, read that. he now is at the families against mandatory minimums. and on my left, jeff smith, former missouri state senator, congressional candidate who a lot of us stumbled upon in a documentary called "can mr. smith still go to washington." he is now an assistant professor at the new school in new york. the reason i bring them here, though, is that they both have served time in prison. so, before we get to the substance quickly, kevin suggested, so as not to hide the ball, why don't you guys quickly, however entertainingly or whatever you want, explain why you spent time in prison. >> i'll make it really funny because it's such a laugh. no. i was a lobbyist and i had the misfortune of working for jack

abrahmoff who was at the time ended up being the leader of the big scandal in the bush administration. and i was basically charged with -- on a services fraud, a junior varsity form of bribery. i contested the charges at two trials and was found guilty and i served 16 months -- a 20-month sentence. i served 15 1/2 months in prison camp. >> i forgot to mention -- i said the documentary name was "can mr. smith still go to washington." i have in my hand jeff's brand-new book "can mr. smith still go to prison." >> when i was in the senate in missouri i was on a panel and the moderator found a question that i took too intrusive and i took the butt end of a bottle and bludgeoned the moderator. no.

actually what happened was that i was running for congress in 2004. we ran like a grass-roots campaign. i was running against a dynasty candidate, russ carnahan. his dad was a successful two-term governor. mom was a u.s. senator. sister secretary of state. we were trying to run a grass-roots campaign and get over the top. three weeks before election day two of my aides were approached by a consultant who billed themselves as a so-called practitioner of the political dark arts. he told my aides that he wanted to put out a postcard detailing my opponent -- it was a ten-way race but detailing carnahan's dismal attendance record as a legislator. they said, he wants to do this. should we give him the information? what should we tell him? i replied, i don't want to know what you do. they said, well, so does that mean we should do it? i said it means you shouldn't tell me anything. do you understand that? they said okay.

so they gave him that voting information, which was publicly available, but it violates the mccain-finegold statute because it constituted a legal coordination between my campaign and a third-party group. i lost by about one percentage point. a week after the campaign my attorney prepared an affidavit to sign in response to a federal election complaint that he filed. he won but pushed this complaint. and the affidavit had 15 statements. 14 were true, one was not. it denied any knowledge about that postcard. even though i knew my aides had met with the person who i figured put it out, i signed a false affidavit. five years later as a missouri state senator my best friend called me. he told me that the man who had done that postcard five years earlier had just been picked up by the feds for mortgage fraud, bank fraud, wire fraud, illegal

weapons possession, spousal abuse -- >> a car bomb. >> cocaine distribution and the chief suspect in a car bombing that nearly killed his ex-wife's lawyer. i let my aides get mixed up with this monster. my best friend and i said, what are we going to do? what if the feds knock on our door and they -- we talked about that. my best friend and i talked about that for a couple months. little did i know the entire time he was wearing a wire. so then i was basically, you know, my only chance to stay out of prison was to do something similar, and i didn't do that. and i was sentenced to a year and a day and was in federal custody for ten and a half months. >> thank you. so part of -- i think where i want to start here is with -- from your guys' experience and from your knowledge

professionally, working with families with incarcerated people, does prison do anything to help criminals, and can it or does it just sort of ruin lives and make people worse off? >> that's a broad question. and i think for some people -- prison serves a purpose. there are dangerous people out there who should be kept away from civil society. i don't think anyone would disagree with that. to the extent that the people are physically dangerous or have a compulsion problem where they will keep offending prison may be the only solution. i think we have come to a point where there is a large swath of people where prison isn't necessary. for those people prison can play different roles. for some there are a lot of people in prison who are uneducated. these are not master criminals. we put a lot of faith in the fact that our criminal laws will deter bad behavior because, if

we ratchet up penalties people will be more inclined to follow the law. that's not the population i met with. these are people who didn't think they would get caught. they didn't give it a lot of foresight. some people just needed to age out. they were immature. they had just limited brain functioning. and they just needed to grow up and mature. there are other people who didn't speak much english, had very limited education, and they were able to get their ged while they were there, and that may have helped.

for most of the people, though, it's just killing time. and people would say, well, that's okay. if you're bored, that doesn't bother me. but it should because while you're sitting there like a can on a shelf, the job market's advancing. technology's advancing. your family's moving on. everything is changing. and you have no responsibilities, really, when you're in prison. you may have a job, but it's a lot of makeshift jobs. and so your skills atrophy. you know, they said man is a creature who can get used to anything. and i think that's what happens to prisoners. you'll hear they get institutionalized. so you learn what it takes to become a decent prisoner. you stay out of fights. you stay out of stupid arguments. you don't touch other people's laundry, you know, that sort of stuff. you know, but you go to the commissary. you have a limited amount of things you can buy. you learn that lifestyle. and for some people who came from really dangerous areas, there's a certain comfort in that. and when they got close to leaving, they were very nervous

because they were afraid of the choices. so for a lot of people, long sentences without any meaningful programming, and we'll address that, because unless you are able to get drug treatment -- you know, for your addiction or you get your ged, there's really nothing else available that's going to help you re-acclimate. and that's a real problem. and so when you look at the recidivism rates and people say these people come out and they re-offend, i know people who are going to try to do the right thing who i served with. some people will be type. some people will try to do the right thing. and after a few years, they won't be able to make ends meet and they are really at risk to going back to the same lifestyle. i want to give jeff a chance, but i want to say there's so much more that can be done on the programming side but it has to be coupled in a way that not only do we treat them more because it's in our interests because that's who's re-offending, but also we have

to shorten the sentences because there's no amount of programming that's going to, you know, sort of satisfy somebody for 10 or 20 years of living in that kind of confinement. >> jeff, did you see anything there where you thought people were being helped or being improved, anybody left sort of, you though, with better impulse control or more prepared for world than they came in? >> not really. i wish i could tell you differently, but in my experience, prison did a lot to create better criminals and almost nothing to rehabilitate people. so there's three ways that i could talk about. so if i'm going on too long, just stop me. but the first way is that prison reinforces people's tendency to operate outside of, like, the rules and outside of the normal economy. and the way it does that is pretty simple. most people have a misconception that when you get locked up, you've got it made.

you've got three hots and a cot and you're fine. but actually, most prisoners are destitute. they don't have a penny to their name. they get into prison. they don't have someone on the outside to put money on their books. maybe some of them do for their first year, their first two years, but then people fade out of their lives and kind of forget about them. and so the problem with that is that not everything -- you don't have it made. in fact, you have to buy your own soap. you have to buy your own deodorant. you have to buy your own toothpaste. so the basics of personal hygiene are, you know -- and if you're living virtually on top of hundreds if not thousands of other people. and hygiene is really, really important for a lot of reasons that i could get into later. but the point is if you want to have a normal lifestyle where you just have basic hygiene needs met, let alone anything else to make your life halfway comfortable, you've got to find a hustle. and so the hustles range from anywhere things that are totally legal, like guys who develop their artistic talent and they draw portraits of other guys,

girlfriends, their children that people can send home for birthdays or mother's day. to things that are a little bit less legal like bookies who make book on the prison basketball games to guys who run barber shops which the prison is fine with to guys who run tattoo parlors which the prison is not fine with to then the most lucrative hustle which is guys smuggling contraband in. there's all types of hustles. i appreciate your words about the book, and i agree with almost everything you said. i found some very skilled men. and i would say that in my experience, there's not a single concept you could learn at wharton that you couldn't learn inside federal prison. new product launch. quality control. territorial expansion. risk management. barriers to entry, supply chain management. i heard every one of these

concepts elucidated numerous times using somewhat different lingo than you would learn it at wharton. but they understood every one of these concepts, and unfortunately there was no training at all to help people translate their intuitive graft of the business world that they had learned through success in the drug world. no formal training to turn those into formal enterprises on the street. there was a computer course that was offered. i'm going to tell a story real quick if you don't mind. about a month -- there were three courses while i was there. there was one ged course that they had a prisoner teach. and so the prisoner didn't really care that much for most of the time. and so if you didn't want to go, you didn't have to go. and then there was a hydroponics course because what better way to prepare someone for successful reentry than to learn how to grow tomatoes in water for two weeks. and then thirdly, there was a computer skills course that was a pre-released course so everyone on their way out

finally, we had been salivating over this room that had 12 brand-new computers but no one ever got to go in it. it was locked the whole time. a month before release, a dozen of us got to go, we sat down at the computers. i was in appalachia in southeast kentucky. and the ceo tells us to sign in. and we sign in the form. and he says -- we all sit down, he says all right. you see that button on the bottom right? push it in. so we push it in. the computer turns on. we sit there for about 90 seconds. then a prisoner says -- starts playing with the mouse. and he says, yo, c.o., if you push the -- shut the [ muted ] okay. we sat in silence for another 35 minutes. and at the end of about 40 minutes in, the c.o. says, y'all remember that little button on the bottom right? well, push it again. and then get the [ muted ] back

to your cell. but since we had all signed in, they could tell the b.o.p. that we had successfully completed a computer skills course, and now the prison could get their stipend from the federal government for having done that. so that i would say was sort of the indicative of the amount of rehabilitation going on. >> so that's where i want to go now is with programming. that it does happen, right? it's supposed to be part of the federal system, the state system and, i mean, do they try it? what can work? i mean, computer seems like a good thing that would learn because that's a huge part of what sort of creates a coming apart in society is that some of us have good ability to deal with computers and others don't. are there career-based things? are there -- could you teach somebody some impulse control, or is it too late by the time they're there? what would you want to see? >> okay.

well, i would just say the courses that jeff talked about, we had similar ones. these are called ace courses. they're taught by inmates. most of the programming there is taught by inmates. and so i didn't take hydroponics, but i could take jeopardy. i could take a class on current events. or crocheting. and get credit. and it was -- it was all busy work. and it was just the prison administration wanted to show that they were keeping us busy. and most of the guys wouldn't even go to the class. they would just sign the attendance form to say that they went. then they'd get their certificate. and when you'd go to your review, you'd give them the certificate. oh, i'm so busy working hard. we're rehabilitating you. so everyone felt good about this but it was really -- i joke about it, but i really think it's so corrosive because these are people who need to learn the rules. as jeff was saying about these hustles. there were people who did all those things. they'd iron shirts. they'd make food. we had bedding. i didn't care about any of that. i didn't really partake in it, but i didn't care about it.

it's just i thought this is the place where you've broken the rules. you're at your lowest of low. this is one the place where you really want to get on board and do the right thing. and the prisoner doesn't care. and so there's nothing there for people so it's sort of idle minds, idle hands. so the program was really lackluster. in terms of the things that i thought, there's drug treatment, but there's fewer addicts i think than people would think at least in the federal system. there were only a couple people who came in that were really strung out and, you know, were in the throes of an addiction that needed help. there were people who had dependency who probably needed help, but it's not necessarily why they committed their crime. they were trying to make money if they were selling drugs or guns. but the thing that i thought was missing the most was some sort of cognitive behavioral therapy, some sort of, you know, psychological work, some therapy. a lot of these folks come from communities where that is frowned upon, and there's people everywhere who frowns upon this. but the lack of impulse control,

the just sort of the emotional disconnect. these are a lot of the behavior there is antisocial. and that's what got them in this position. and now they're going to the most anti-social place in the world where you're walking around with headphones on screaming your music to no one and no one can tell you to be quiet because no one's going to screw with you. i mean, it's just -- it just perpetuates the worst behaviors. and so i think the fights that you'd see would be over turning the tv channel or somebody, you know, calling a foul in a basketball game. and those are things that you have these people in a fishbowl. you have them there. they might not seek this help otherwise. but while you have them there, there are certain things you could do to work with them to get them thinking about their thinking patterns. get them thinking about their behavior and the choices they're making and the roots of those choices. people do what, you know, they were raised to do, and they're not thinking about it otherwise.

even those of us who try still struggle and we have to remind ourselves, wait a minute, why do i feel this way? these guys aren't thinking of any of that. and it's not cool to think that either. at cumberland, we had 250 prisoners and we had one trained psychologist. and she was the head of the drug treatment program. she didn't want to do any more work than that. so when i was there after a little while and i had two young girls who i was missing terribly and i knew some of the other guys were missing their kids, we talked about putting together a group that like that was an aa and na, different support groups. we said let's put together a fathers group so that we can talk about ideas about how to stay in touch with our kids, how to use our minutes, how to use things like finding the guy who creates pictures that we can send, anything you can find to stay close to your children, that's what you want to do. and you also want to be able to just say, i am bummed out. i'm dying. i had a visit this week end. i'm really sad. you don't go cry on your bunkmate's shoulder. it's a men's prison. so to have a group like that, i thought okay, this will be a

sure winner. the psychologist wanted no part of it. she wouldn't respond to my e-mails asking if we could put that group together. there's a lot of lip service and talk about family reunification and how important it is to stay close, but there's not a lot that gets done. as jeff said, that c.o. who said, you know, now you can leave, that's the level of concern. it's sort of i checked the box. i gave you your computer training. it doesn't matter if you learned anything. there are things that can be done. they're not being done. i think some states do a better job from what i hear, but the federal government is really far behind. >> so i'm going to ask you in a second about something you alluded to i think you use in your book, the phrase convict code about how you have to behave to not have other prisoners make your life horrible. but before you talk about that, i want you to just say what you can say about programming. do you think psychological help is possible, helpful? what are your thoughts on any of that? >> so i agree with everything kevin said. you guys had crocheting?

wow! we didn't have that. >> and i'm a master now. >> i actually applied to teach current events. i topped out to teach five different courses. instead i was put to work -- i see a couple of you have the book. if you turn the book on the back, then you can see what my job was. those are my -- i worked in the warehouse on the loading dock. and you can see my crew that i worked with. you can probably tell which one i was. anyway. so no, i mean, i'm not trying to be like you do the crime, you do the time, you know. and you do the time how they want you to do the time. not how you want to be the time. and so i'm not going to complain about my job. but i definitely think -- you know, i had a decade's worth of teaching experience. and i had been a state senator. and i would have loved to have teach a course. i applied first to teach a black history course because i was a black studies major in college. and most of the prisoners were black. and i thought that could have been interesting.

i wanted to teach a current events course. i applied to teach -- then i realized, like, anything that had any political or ideological charge was never going to fly. and so i applied to teach, like, a job interviewing course and, like, a resume writing that could teach guys a little more about that. but everything got -- they ignored all five requests. although about three weeks before i got out, they did finally move me. which was interesting. i had fallen off of -- i worked -- we moved about 35 or 40,000 pounds of food a day into freezers that were bigger than this room, and i fell off the top of a freezer. a few weeks before i left. and then i don't think they were going to move me, but the lieutenant governor of missouri happened to visit the next day. and then they figured that he might have come in response to me falling, even though it was totally a coincidence. and when they figured oh, you might have some juice behind

you, then they did move me. and then they sent me to the education department. and then i was heartened, at least it wasn't going to be long, but at least i hoped i would get to teach. and the guy in charge of it, he said -- he said inmate, what's your education level? i said a ph.d.. and he said, all right. we'll start you off sweeping the classroom. and so i swept the classroom for my last month. >> one thing i would say, not to put it too much just on the bureau of prisons because i was going to teach a writing class as well because a lot of guys asked me to edit things they were doing either court filings or course work doing correspondence courses. and they would ask me to write. and i think writing is a lost skill anyway. but in prison, it's pretty miserable. and so i said, you know, some guys said oh, would you teach a class in writing? same thing, resume, cover letters, just basic letters like that. and i had to say, part of the problem was that no one would have come. i mean, a couple of the guys would seek me out privately, but

they weren't going to come from 5:00 to 6:00 at night because the prison wasn't going to make them. so there were some guys who were interested, you know, but i don't want to put it all on the prison. the prison should have made them come. and i said to a guy -- >> if anybody can compel someone to do something. >> well, that was the thing. the head of education, he said -- he was talking to another class. how would 50 people go to this class. it was an electrical class. wait a minute, if they're not going, why am i giving them all certificates? because you don't know who's there and who's not. how do i fix that? you stay and you check attendance when people come in and out of class. he said all right, forget it. >> so what you said really spoke volumes. the first thing you said, you said oh, people would come up to me and ask me for help, but they wouldn't go to a class. that's what i experienced all the time, people wanted help. they wanted tutoring on their ged. they wanted me to help write a resume, all that stuff. they would quietly come to my cell and ask. so there's definitely interest

in it. and i would actually say, like, a pretty insatiable thirst to, like, figure out what they're going to do next and how they're going to acquire a skill. but yeah, doing things formally through the prison wasn't always interest in that. so there's a lot of research actually on prison education programming. and the rand corporation just did a study. they did a metastudy of dozens of other studies of prison education programs around the country. and it shows that first of all, there's a 43% reduction in recidivism for prisoners who advance educationally while they're incarcerated. secondly, for every dollar we spend on prison education programs and vocational training, there's an almost $6 return in reduced costs related to that recidivism. and that makes sense if you think of a 43% reduction and you think it's costing on average about $31,000 a year to incarcerate someone, then you can see how much money we could save doing it. so what kind of courses -- so you talked about therapy. i mean, therapy would be so

important because people don't have an outlet. like what prison -- prison teaches you so many things. it teaches you a way to behave like to suppress all emotion all the time. >> this is going to be my next is you do talk in the book about the convict code that, you know, making eye contact or, you know, seeming too friendly. i mean, there's a way you have to behave, which is antisocial in a way. that you have to learn rules of survival that probably are counterproductive outside. is there anything -- i mean, i can't imagine that being something that at all would be easy to fix. or is it rooted in the fact that it's sort of the prison versus prisoners? is there anything that could be done, if you were just dreaming that could make prison not foster that code of -- that pushes people toward antisocial behavior? >> so i would say yes, there is. like that code, you know, what results is number one, a tendency to suppress all emotion

because you learn very quickly that any show of emotion is a show of weakness. right? to be like i'm so excited for the visit i'm going to get this saturday. no. don't say that. okay? you don't -- you don't long -- you don't tell anyone else about your family. you don't -- you know, tell everyone how much you miss, you know, your kids. you don't do anything because then they know how to get to you. right? and people -- there's a lot of people that play a lot of mind games in there. they have a lot of time on their hands. they've developed really sort of acute senses for other people's weaknesses, and they will prey on that. so you learn not to express any emotion. you, of course, develop a tendency to overreact to small slights because if someone cuts in line ahead of you and you don't step to them, then you're weak. and everyone knows you're weak. and then people are going to find other ways to try to exploit that. and so all these tendencies that you develop of course are totally dysfunctional out in society. and that's the root of the problem. does it have to be this way, you ask? no, i don't think it does. i've been in a prison in texas

that was the most positive place where the camaraderie and the enthusiasm for learning exceeded anything that i've experienced among ph.d. candidates at the new school. i'm being honest. there was a nonprofit called the prison entrepreneurship program which full disclosure i'm on the board now that operates inside two prisons in texas. they run a nine-month-long mba-level curriculum where it culminates in prisoners who compete in a shark tank-like business plan competition. they have nine months with the help of visiting executives and mba students from all over the world who advise them on the creation of these business plans. and the sort of positivity and just genuine, like, care and concern and even love for one another was i felt like, you know, it was similar to that of, like, a great winning high

school team or college team. and the recidivism rate for graduates of that program over the last 11 years, 6%. >> wow. >> less than one-tenth of our national recidivism rate. and several men have started multimillion-dollar businesses as well. so i think there are ways. we see examples of ways to create an atmosphere that's very different. >> so that's cheering that there are examples of these things being done right. >> yes. i'm going to -- i don't want to disagree. and this is -- and again, when i read the book, it was -- i spared everybody telling my story because he really told it perfectly well. the one thing i would say about that is my sense of some of the folks there was there was too many, you know, bill gates just waiting to be born. and i think i'm afraid that sometimes we romanticize the prison population to think that these are people you'd have to a dinner party. this is, you know, everybody's least valuable players.

it's not a great group of people to hang around with. i mean, you say that -- i mean, i was there. i'm not trying to be above it. if i said these things there, which i would do, people would put it right back on me that i was with them. and i get that. it's just these are, you know, low skill, low education, bad social skills, all of which i think can be dealt with. but i don't want to mislead people into thinking that they're all budding entrepreneurs because what worried me the most is when people would come up and say, hey, i've got this, you know, business plan. i'm going to come out with an app. they didn't even know what an iphone was. but they had an app that was going to sell. it was going to be like gangbusters if somebody just heard of this idea. and they had been sitting there for six, seven years. they had no market research or anything like that. they didn't know what they didn't know. so i felt like with some people, you shouldn't worry about being your own boss when you get out. you should just go hope to be a cog in a machine somewhere. like you don't need to compete with walmart.

you just need to be a greeter at walmart. just hold a job. get something that pays the bills and supports you, and don't crush your dreams. but you're going out with a felony conviction. you don't know what the job market's like. and so i thought the prison could give people a little realism, too, by giving us so much space, they let people dream really unrealistic dreams, and i thought that was really counterproductive for the people who really needed a dose of reality as to what they were going to face when they got out. i was the exact opposite. i was so fortunate. my circumstances are so much different. so, you know, i could exempt myself prosecute that. i knew what i was going to do when i got out, but a lot of these guys don't, and they get scared. but if they're allowed to dream unrealistic dreams, i don't think that's healthy. >> i want questions from all of you guys in a minute. so i have one last topic for these two. reentry when they get out of prison, you know, is there --

are there existing programs -- i mean, you studied that work and also just so that -- i mean, people here who haven't had anybody close to them go in and come out of prison, i mean, what are the challenges besides not having seen an iphone? >> so a huge challenge is family and community support. you know, we talked about how heartbreaking it is to watch men who work -- i don't know what your wage was for your job, but i made $5.25. >> a week. >> which a lot of people say that's not bad. and then i tell them that was my monthly. >> a month. >> you know, for 40-hour-a-week work in the warehouse. but of course, like you, i was lucky, right? like i had money. i mean, i didn't have a ton of money. and most of it went to my lawyers. and then i had to pay a big fine to the government. but i still had enough to have someone send me 100 bucks here and there. i always had money when i needed it. most of these guys, you're working.

you're making somewhere between $5 and $25 a month. and not only do you have to buy the basics of like, personal hygiene, but sometimes you have child support arrears accumulating while you're incarcerated. and then, you know, just to try to stay in touch with your family where i was, the interstate phone calls were, like, you know, $1.50 a minute for me to call home. other guys, it was even more. there's some prisons as much as $14 a minute. now, the fcc just changed that in a ruling that came out last week thanks to the great work of f.a.m., kevin's organization and some other organizations as well. but this is, you know, a huge problem upon reentry is the resentment that a lot of family members have because guys didn't stay in touch and they don't fully understand just how hard it was to get the resources to stay in touch, right? and you never tell people how bad it is in there. you don't tell people how hard it is. that's just part of the code. you don't want people feeling even worse than they already feel.

so you say oh, everything's fine. so family and getting family back together, that's a big cal ledge. obviously the fact that 90% of employers perform background checks is a huge obstacle. one of the reasons i'm such an advocate for entrepreneurship is people won't hire you. i don't want to be misunderstood. >> no, i though. >> i know we might have a slightly friendly disagreement about this stuff. but basically, these guys, like, you know, they could run their own trucking company if they get a cdl. they could run their own landscaping business. they could run their own barber shop. they could run, you know, their own janitorial business. they have that entrepreneurial spirit that in many cases led them into the drug trade because i don't want to work at mcdonald's and make 7 bucks an hour. i want to do better. the challenge is channeling that energy into something that's a legitimate enterprise and then also like literally, like figuring out a way to get them, you know, just the sort of basics like a halfway house, my halfway house was worse than my

prison. i don't know what yours was like. but my halfway house was crazy. you know. and when you put people right back in that place, you know, 650,000 people every year come back to the doorsteps of our communities, the same communities where they've already failed except now they've got the added stigma of a prison record and they're broke and they have to pay for their halfway house rehab, and they have to pay for their drug testing, and they have to pay for transportation and clothes to look decent at a job interview. it surprises me sometimes that one out of, you know, three people don't reoffend. you know, how they're able to get back on their feet. you know, we need much -- we need practical, we need therapy, you know, therapeutic resources, not a p.o. that's, like, be here at this time. if you're late, i'll violate you. you need to be here for the drug test. but somebody to counterbalance that and say how are you feeling

about being back here? what do you need that can help you? can we help you with bus passes? can we help you learn to use the internet? you don't know any employers? you don't have anyone you can list as a reference? we've got some people who you can talk to. a database of employers like second-chance employers that are willing to hire people. it's great to see coke and walmart be in the box, but we need proactivity. we need people to step up and say what are the resources that it takes to identify, recruit, you know, hire and then support and retain people who were incarcerated? >> i mean, and i'm, again, a conservative libertarian guy, but that sounds like the perfect sort of thing for a nonprofit on sort of local-by-local, state-by-state level to do. do you think that should be part of the criminal justice system to do that, or would you see that being done outside? >> there's an amazing company that started a foundation. the company is called dave's killer bread. dave wasn't a killer, but he was -- he was incarcerated, and

he was the brother of the company owner. and he came out and they said we want to help you, you know. can you bake some bread? he starts baking the bread. you know, there's some good cooking in prison, isn't there? like i miss the nachos. but he made the bread like totally different. he experimented with all kinds of stuff, and it went nuts. and everyone wanted it. and it grew like hundreds of, you know, and now it just got acquired by a much bigger company because it's been so successful. and they decided they were going to make it their mission to be a second-chance employer. almost 40% of their employees are people who came out of prison. and they just put on a big summit for employers all across the pacific northwest to learn what they're doing. and so yeah, i mean, i think -- i think government could have a role in connecting people in giving people more than 20 bucks and a bus ticket back to

wherever you're from and connecting you to those resources. i'm not optimistic given my prison experience that they're going to take that seriously because frankly one of the c.o.s when people would leave, his line would be, he's say, i'll see you in six months. it's jackasses like you that remind me i'm always going to have a job. >> yeah, yeah, yeah. i would say -- i'm a small government guy for the most part, but i think the reason there's a role for the government is because the halfway houses, you're still under the department's control. we're still -- i was still serving my sentence when i left. so i had to do home confinement for a couple months. and i got to go to rockville and quickly get to home confinement. but if i had to go to hope village in d.c., i know a lot of people have been to hope village. it's way worse than your prison for most people. i mean, c.o.s are stealing things from the inmates. and some people at cumberland would pass up their halfway house time. even though they wanted to be closer to their family and community and start getting a job, they didn't want to go to the halfway house.

so i think there are minimal standards that could be set to control these. rockville, even though i didn't have to spend time there, they have a good reputation because they really spend time getting people on the phone. they require them a certain amount of time applying for jobs. that's their whole focus is you're going to apply to ten jobs a day. and so there's a set period where they're making them do that. so they're really on them. and so i think that that's a good thing. you mentioned coke and walmart. and i would just say this is one of those cultural changes that need to happen. >> explain more. not everybody -- >> oh, i'm sorry. so coke, walmart, target, some of these companies have just voluntarily said we're not going to put on our application whether you have a criminal conviction. we'll find that out, right? i mean, through an interview process, but we don't want to knock you out of the consideration based on that one fact alone. so that's a smart move, they did it on their own. there's no law that requires that. president obama just announced he's going to ban the box for federal contractors.

so that's not asked. i'll just say this. you know, as a conservative, i think an employer can ask whatever they want. so this idea to me is less about what it's actually going to do because, i mean, all the guys i served with, they could not get asked that. they'll submit their resume and there will be a ten-year gap. so it's not going to take long for somebody who figure out where you've been. some people list their prison jobs. because they don't want to have that gap, and they did do some work. so i'm not so optimistic about that. it has to be a cultural change. there's no law that's going to do this that's going to make people hire offenders and give them a second chance. we have to do that. i do not -- i have to do community service because after two trials, i couldn't afford to pay a fine. so i have to do 200 hours of community service. i live in montgomery county. if there's more progressive or proud of its progressiveness county in the world, i don't know it. it's bernie sanders, war's not the answer, hillary's a fascist up there. and so this is the greatest

place you should be able to come home to, and yet i got turned down by three different places to do community service because of my felony conviction. the places had blanket policies no the to hire felons. i don't seek to be paid. i have a law degree. i just want to stack books in your used bookstore, but they will not hire me. so forget ban the box. forget about even not asking me, getting rid of policies that don't even allow you to consider me at all. and so again, i think it's cultural. i think it's just us saying and knowing more people who have gone to prison saying i'm not going to write you off because you served some time. i'm going to judge you as an individual. i'm going to get to know you. and i think that's what has to happen. that's not a government solution, though. >> so one possible government solution, and we might disagree on this, i think that even people on the right, i think definitely people on the right might find this interesting. remember what i said the c.o. said when people got out? that really embodied the incentive structure as it

operates for prison wardens and prison administrators and c.o.s. they have a job because they know there's going to be a constant supply of us. what if we turned it on its head? what if we gave stipends or bonuses to c.o.s who worked in prisons? basically if we tracked everyone who came out of prison and if they went five years without recidivating, then we gave a $5,000 bonus on the c.o.s at the last two prisons where they were housed. maybe if we turned the incentives on their heads, then prison guards would be more focused on boosting you up than tearing you down. >> i totally agree with that. i would take the sort of warden or the head of the facility. i'd put it on him to create that culture. and i certainly would want to know -- i mean, i think wardens judge themselves now on nobody escaped today, you know? that's, like, all right. but everybody leaves your prison is reoffending. and we want to know that. so the bureau of prisons could

at least track that information. how are different facilities doing? because we also build tease prisons in dog patch, usa. so a lot of people that are guards that jeff has imitated very well were the type of people that i had in cumberland, and they were this close to being inmates themselves. and i didn't find them any more moral or educated or anything than the people that i was serving with. and so what's this -- what's the training for them? what is their background? why isn't the head of my prison know something about psychology and motivation? like instead of insulting people, try to build them up? >> is there any state or locality or county where there are -- that you guys know of where there are sort of good incentives or wardens are given a job which is to help people or -- >> i know this idea has been discussed. i haven't heard it implemented. >> you know what? i'm going to be the commit some liberal right now. >> i just want to quickly say, if i hadn't said republican study until about five minutes ago, you couldn't have told that he was a republican, he was a

liberal. now it's all going to come flowing. >> but this is sort of -- like the people who have done this the best over the last few years are like, nikki haley in south carolina, nathan diehl in georgia, rick perry in texas. the texas recidivism rate is, like, just a little more than one-third the national average. texas recidivism rate is, like, 23%, right? they're doing great. the best prison i had ever been in, that's in texas. they, you know, and the liberals and cynics might say, well, the reason the recidivism rate is so low is because at the execute so many people. there's 236 people who couldn't possibly recidivate. i will say this. conservative republicans and southern especially in the south governors have really led the way over the last five or six years on both on the inside -- you know, on the front end on sentencing reform and then on trying, you know, to be more compassionate inside of prisons in a way that will reduce recidivism. and it's a credit and nathan diehl's made this a focus of his governorship. john kasich in ohio. not only did he focus on this,

but then he ran for re-election on specifically, you know, this issue which is pretty encouraging to me. so -- >> audience questions. yes. we've got a microphone. it will come to you. please -- yes. >> my name's dave price, retired journalist and educator. i want to begin with an accumulate and then go into my question. first, thank you. i'm sure there's times when you regret what happened to you. but it's been my impression working in urban schools and areas that the one population that probably is least represented is prisoners. both while they're in prison and even more so when they come out. so i think that's good. and my question kind of comes along with that. you talked a little bit, jeff, about this, but what's been the reaction not so much to you personally but to your message? i think it's such an important message. you're out there delivering it. do you think people are hearing you? and if they're hearing you, you know, are they beginning to act,

you know, obviously it's going to be a multiple of things, but just the message. how's it being received out there now that you're giving it as an expert? >> and also along political lines, is it being received differently? >> yeah. it's just as you'd imagine. some people -- you know, i didn't want to be the guy who came out and was the expert, right? and it's not because i didn't want to relive the experience. i worked for families against mandatory minimums before i was indicted. so i was involved in these issues. i had been on the wrong side of these issues on capitol hill. i wrote mandatory minimum laws when i was a senate staffer and i was young and i knew nothing but i thought i knew everything. so part of this was a little bit of penance and just the idea that it didn't appeal to me as a conservative anymore that we would let politicians draft sentences for cases they knew nothing about. so i thought i wanted to get that message out. and i am lucky that as jeff said, there are so many other conservatives who are doing that. on a personal level, you think

you're getting so much support, right? because those are the people who are talking to you. it's sort of a self-selecting process. i know there are people who -- what i don't like is in any other walk of life experience matters. and especially for conservatives, if you're a businessman and you're complaining about the epa, people would say you know because you're out there and if people are screwing with your business, we want to hear your viewpoint. my experience with the justice department. they say oh, of course you say that because you broke the law. so, you know, you've got, like, bernie kerik. nobody's done more to fight crime individually than bernie kerik. he was the nypd chief during 9/11. he ran rikers island. if you're going to dismiss him because he's got a conviction. jeff never talks about reforming the law where his conviction was. i talk about mandatory minimums. i wasn't subject to one. kerik doesn't talk about tax reform. we're talking about the system that we saw. and unfortunately we have experienced. so i'm a big boy. i can take it, but i don't like when the discount and that experience is discounted because

people think it's a motive i have. i'd just as well not talk about this. but i was there. i saw it. i helped create a bad system, too, as part of a staffer, being a staff. so the reaction is mixed. >> obviously, there's that sample bias of, like, the people who come to events that where i'm selling my book are probably going to be people who are favorably predisposed to the message. but the most heartening thing i think is that i've tried to go to places that are unexpected, you know what i mean? i go on conservative talk radio. i go, you know, i go wherever i can. if people invite me. and i have had very, very few people come back to me and say, well, you know, what about, you know, what about rapists? you know, and i actually talk about rape in my standard talk because i think it's important to talk about it because what --

there's no clear example of how we operate our prisons, driving recidivism than rape. you know, because we tolerate rape culture inside of prison. there are more rapes that han in prison every year than happen on the street, than happen outside of prison. and how do we handle that? well, we laugh about it. like our pop culture, it's a staple of our detective shows, "law & order" to say hey, the prosecutor says don't drop the soap to the perp who's going away. i mean, how calloused do you have to be to think that no matter, you know, that no matter what happens to you on the inside, you deserved it because you broke the law. that's crazy. and unfortunately, a hugely disproportionate number of men who are raped or gang raped and repeatedly so on the inside come out and tragically attempt to reclaim their manhood in the way they perceive it was stolen from them on the inside. and so, you know, i am trying to talk about issues that a lot of

people don't want to talk about. in some ways i'm a good messenger for it because i was a policymaker, and i actually worked on criminal justice reform as a policymaker. and then i am a researcher, too. and so i can bring that angle. in other respects i'm not the right messenger. i'm a white, you know, highly educated, i'm not representative of the prison population. but in a perverse way, i can reach people in a way that other people can't reach so i'm hopeful i can do that and spread the message. >> speaking of why you may have noticed that we are all white, he was attacked. jeff was attacked in his campaign as a well-known caucasian when he was running -- >> known caucasian. >> known caucasian in a district that was largely black. we invite people here, we try to get a diversity, some people say yes, some people say no. so i want to apologize for that. yes, sheryl. >> hi. i'm sherylyn, a lawyer and a writer. we've got 6,000 federal prisoners that are being released.

jeff talks about in his being boo about the reason why -- one of the reasons why he was doing the -- i think you were doing inventory on the loading dock is because he had -- he could read. and he had math skills. so i'm curious. there's been a lot of reports about how there are a limited number of books in prison libraries. they don't allow newspapers. so what are these 6,000 prisoners going to do if they can't even read? and have minimal math skills? i mean, you can't even bag at the grocery store without having literacy skills. or math skills. >> i mean, either of you experience this also, illiteracy? >> part of this is, again, not

everybody's in there dying to read. you know, some people can't and want to. some people really do use that time to self-educate because there's not classes. you know, when i was -- >> that's not the norm. >> no, that's not the norm. if they were -- if these guys were really starving for education, i mean, some of them, they wouldn't be in the position they were in. >> sure. >> but, you know, so in terms of the 6,000 coming out, i just want to say because f.a.m. has been having to respond to this a lot, this was not the obama administration's decision. this was the sentencing commission. and if we cannot tolerate this 6,000 who really are the lowest -- >> say more about -- >> okay, i'm sorry. yes. so there's been news reports about 6,000 people being let out early from federal prison who are drug offenders. and if you listen to bill o'reilly, you think you should run to your basement and lock the door because they're all violent folks. they're not. i was in prison. i just got out six months ago. i was there when a lot of people got their letters saying that

they were getting the two-level reduction. so what happened was the sentencing commission over a year ago said the drug sentences were too high. the guidelines were too high. and since your sentence is driven by the weight of the drugs, they reduced the trigger for that. for most people they just got a slightly shorter sentence. 11 years went to 9 years. and they made that change going forward, but they said it's not fair to not include that for the people who are already serving. let's get rid of some of the overcrowding we have. and just as an equity matter, let's do it this way. so people were allowed to go into court. they had to have a good record. the prosecutor was allowed to object. the judge had to agree to this. so the people that are coming out, you know, there's been this scare -- fearmongering going on about 6,000 people. well, federal prisons let out 70,000 a year. state prisons let out more. these are, like, a handful in each community. and these are people who are serving drug offenses who served substantial amounts of time who were coming out anyway. so if you were worried that they weren't ready for society, they weren't going to be ready in a

year and a half either. so it's the biggest nonissue, but it's been turned into something big. and what scares me about it is if we can't -- if we can't welcome these people back, then those who want to tackle, you know, the bigger prison issues are going to have a hard time because these are the lowest hanging fruit that we have in the system. >> pie question, though, what are we doing to help them? and even the ones that are much more -- that have much bigger problems? i mean, these guys are the lowest of the lowest, but do they have literate skills? >> we're doing with them what we do with everybody, and it's not enough. >> exactly. >> but the reason they delayed the decision was for the past year these people would transition to halfway houses, home confinement, look for work. so it wasn't as if on november 1st, 6,000 people walked out the prison door. but if you're talking about what we're doing to prepare them, i think that's our whole point is not enough. >> some of this, i mean, there's been -- you guys have mentioned some examples of things that

have worked in some cases. and a lot of them, you know, you talk about the texas case or these other reentry programs, rockville having some good programs. in a lot of these, i'm almost feeling optimistic that we have some solutions that are worked on a local level and maybe they can be expanded and adapted to other situations. but on the question of people who are illiterate, getting an education in prison, is there any examples of that being done well that you guys know of? >> well the problem is it's anecdotal. and i think this is a problem with the criminal justice system overall. we don't have good data. if i said what's the recidivism rate, you would give a number that you heard. but if i said well, is that the number of people going back to jail or the number of people just reoffending? is that the number of people who have technical violations? you'd start to drop off and not know. a lot of researchers don't know the answer to that either. we don't have good data. even when we talk about programs that work, what the b.o.p. needs to do is also assess its programs. i'm all for them investing in

programming that we think work, that reduces an education is a good example of that but i want that measured and tested. and then if it works, you know, sort of spread elsewhere in the country. >> that might be the most aei answer as possible. the answer is we need more data. >> yes, more data. >> yes, in the front table here, microphone is coming from right behind you. >> good evening. my name is elizabeth charity, and i'm the ceo and founder of youth corporation inc. services. i was, of course, in the corporate world. then what i did was i lost my job. and i started a volunteer in the juvenile justice system, in the juvenile detention center. and whilst i was there, i volunteered for, like, 20 -- it had been about 20 years. and what i did was i wrote a grant, and i gave it to -- submitted to the former governor george allen.

and i started that 12-week job readiness program. but during that time, what i decided to do is come and go back to school to george mason university. and i did a study on training the ex-offender to a social entrepreneur. i put together that 12-week curriculum. i have submitted it to george mason university. and what we are planning on doing is getting college students to come in and help us teach that 12-week job readiness mentoring program, but we want it to go into the juvenile detention center. we have been given the opportunity to be able to go before the juvenile -- the department of juvenile justice to introduce this formula, and i truly will love to have some of your statements included in our study. this could be, like, a two to three-year study in which we can be able to get the data and all

that information. >> i mean, so my question following up on that incredibly interesting sounding project there is on the juvenile level, have either of you done research or looked into that? that seems like that has a whole different set of needs and problems for juvenile offenders. >> it does have a whole different set of needs. and one of the most disturbing things that i uncovered in my research for the book was the number of states that put juveniles in solitary. i mean, juveniles are so ill equipped to be -- >> yes. >> no one should really be in solitary except in the most extreme circumstances pretty much across the world, the civilized world. they've decided you know what? this is basically slow-motion torture to do this to people. but, you know, where i was, i don't know if you had this experience, but, like, you know, you'd have a guy on your basketball team. and, like, he wouldn't show up for the game. and you'd be, like, where's cee lo? he gone. where is he? he's in the shoe. like he's in -- he's just gone.

you don't know why people leave. they just disappear. they're in solitary, and then you never see them again. like the people who came out of solitary, i mean, they were broken people. right? it had broken them. and so, i mean, the number one thing i think we need to do in terms of juvenile justice in this country is to absolutely forbid juvenile solitary because no young person especially given their neurological development at that juncture should ever be put in solitary. that's the first thing. but, you know, i think we need to look further back. you know, everyone now is talking about the school-to-prison pipeline. and it's real. a friend of mine named karla shed just wrote a book on this in chicago. she looks at, you know, just the way that, like, poor kids mostly of color in our society like from the minute they go to school, they're 5 years old, they're accustomed to, like, metal detectors and, like, you know, this sort of things that we know of as, like, the carceral state.

so i think we need to go even further back than the juvenile justice system and make it so that it's not considered -- and stop normalizing the experience of the criminal justice system for a big subset of our population. >> again, i want to know if i can be able to get statements from -- >> we can talk about that after. >> okay. thank you. >> man over there in the salmon-colored shirt. >> thank you. my name's jacqueline fefer meryl, and i serve on the board of the advocates for the prison partnership which offers programming on a high end above the cliche. we support goucher prison for a medium-security prison in jesup. i want to ask about here we have a very friendly audience. but talking to people who are much less sympathetic, whether we're talking to a c.o. who might have only a ged and no longer gets a subsidy from the

department of corrections to take a community college course or taxpayers who are struggling to, you know, finance their own kids' college education, how is it that we talk, we saw the troubles talking about this in the state of new york about offering, whether it's college education or other education and spending yet more money on incarcerated people and help them see that it's really worth it? because having talked to the skeptics. >> kevin. >> yeah, i talk to the skeptics a lot because i was once one of them. and so sometimes that helps is that i remember what i was thinking when i was at that point. and it's still helpful sometimes to be working on these issues and talk to somebody on the hill who's, like, why would i ever shorten a sentence for anyone who committed any crime? you know, you think, wait. because there's no evidence that it's reducing crime. you know, it's like it's not helping recidivism. it's costing money. but, i mean, there's still just this -- turn on fox. >> especially among

conservatives. there's this deeply ingrained sense that justice needs to be served. that these people do not deserve our sympathy or our help. >> until they know somebody who runs and follow the law. that's happening more and more. some of these people who are come out and are now supportive on the right just look through their family tree for a minute and you're going to find somebody who went to jail and all of a sudden they have a firsthand experience with the criminal justice system. some get it. some just weren't around during the old crime fights of the '90s where they don't have scars of me tough on crime you soft on crime, that old stale debate. how to talk to them, i really think it is about appealing to their self-interests because you can't make somebody always feel compassion. f.a.m. talks about personal stories. and that reaches people. in a lot of cases. but sometimes it's just -- it's not that -- i don't want us to not be tough on crime.

i just think what we're doing isn't tough on crime. it's tough on criminals, on individual criminals. and so if i want to show how tough i am and i send somebody to 20 years, i may feel good about how tough i was vis-a-vis that person, but if i've just made them a worse offender, if i've destroyed their family and so now those kids are more likely to go to jail, if i'm just driving up the costs across the board of what i've done, then that's not being tough on crime. it's just -- and so, again i do think this is a cultural issue that is not so much legislative. i think we are very vengeful. i think we -- i'll give you an example. there were lobbyists who are doing just what i was doing. and half of them will say gosh. but for the grace of god, go i. the other half, even though they knew what they -- i was doing exactly what they were doing are, like, you asked for it about and we have that. there's something weird in our society where, you know, if, you know, all of a sudden speeding on the beltway, you know, got you ten years, we all do it. but the person who got caught,

we'd have zero sympathy for. and so there's a quick -- it's an evolutionary thing we have that once you break the law, you become the other. and we don't have to feel any sympathy or empathy for you. and that's just going to take us growing out of that and part of it is when i grew up, i didn't know anybody who went to prison. i don't think my kids know anybody who doesn't know somebody who went to prison. so we're going to get to a point where we're going to jail so many people that we're all going to have more firsthand experiences here. and that may be what it takes. >> just very quickly. i totally agree with kevin, self-interest. you feel -- money and public safety. is how i talk to conservatives. you know? you like spending $80 billion a year of your money, you know, on a revolving door? >> then they say well that's because they get plasma screen tvs and comfy beds. you got the comfier bed. >> yeah. my bed went from this thick to, like, that thick. so -- and i talk about public safety a lot, which is like, you know, if you -- you know, these

people, like 93% about of prisoners in this country are coming home. and what we do to them, like, we are -- our own nest, right? these are americans. we will see them. they will be, you know, maybe they won't live in your suburb, but when you go downtown for the opera or for the baseball game, you will see them. and if you want them to come out even more damaged, broken and angry than they went if, then you've got the right recipe. >> yes, sir. >> good afternoon. great talk. obviously very entertaining. but in speaking of entertainment, before i ask a question, i wanted to know, are you familiar with a comedian kevin hart? >> yeah. >> so i went to see him recently.

and i can relate to him because he's under 5'9". i'm 5'7". he might be 5'4" or 5'5". so it's even tougher for him to be even that much shorter. but he does this joke about how a series or monologue about what it's like to avoid fights and why he avoids fights. and it's interesting to hear the rationale he uses because he basically says i know what the consequences are going to be if i get into a fight with this person. and so i think there's a difference between the way some people think when they say well, if i get into a fight with this person, i'll do this and it will come out okay versus someone who says no, it's going to come out bad. i think i need to walk away from that. so i've been able to stay out of prison because i've avoided a lot of situations where i could have made the wrong decision. and maybe it was because of my mom or my dad or going to catholic school. i don't know what it was. but as a result, i would be -- i know i would be the whitest guy in prison if i was there. i would be the whitest guy. i would be the guy they would

pick out and say you, uncle tom, i'm going to do this to you, right? so i want to ask you, do you or do people that you've spoken to actually believe that what some of the things they did that got them put into prison were actually wrong? because i think -- and this is my theory, and i don't know a damn thing about it because i've never been to prison, but i think there's a point where you decide, hey, you know what? maybe i'm wrong. maybe i should have been put in prison for some reason. there's no perfect answer, but i'm going to start reading the bible. i'm going to start doing these other things. so do you think that anything that you did was actually -- because i don't understand anything that you supposedly got put in for. was it wrong or what? >> i lied to the feds, you know. and it doesn't matter whether you lie to the feds about jaywalking or structuring financial transactions or killing someone. you still lie to the feds, and i lied to them about whether i knew that a meeting took place between my two aides and a third

party. i said i didn't know about that because the mailer didn't have the appropriate paid for by disclaimer. so it sounds sort of technical, but the underlying crime was a campaign finance violation, and then the obstruction of justice was signing a false affidavit saying i didn't know anything about that meeting. so that's what i did. do i think i did anything wrong? i think i broke the law, and, therefore, you know, in this country, i have done something wrong. i think i did something really, really stupid, okay? and it was a big mistake, and i learned a lot from it, but i also have perspective on it, and you get a lot of perspective on it by watching like the presidential campaign this year where basically what i did, it was a $10,000 postcard and right

now i don't want to get into too many details but basically jeb bush has a super pac that's got over $100 million in it, and his like political alter ego who he spent the last 20 years plotting with is running that super pac and so they don't really need to coordinate because they spent the first six months of this year figuring out exactly what they were going to do with that $100 million. so they don't have to have a conversation about it now. i was an amateur. i was naive and stupid and so as a neophyte, i made the mistake of doing it in an illegal way. what some politician has probably done since we came here together at lunch today. but the fact is i did the crime, so i had to do the time. in prison overall one of the biggest myths, biggest misconceptions is that prisoners all say like i didn't do it. they know they did it. they'll tell you they did it, and in fact, one of the guys i

worked with in the warehouse used to joke -- one time -- it's a long story but they -- they were going to plant raw meat in my freezer jacket because they were going to get me in trouble because i wasn't stealing, and so therefore they thought i was a rat and i was going to snitch on them for stealing. so i had to start stealing, and it's a long story but basically like -- there was a threat i would have to go to a high security prison, and i was like i don't want to do that. that's why i decided to start stealing because i didn't want to go to a max, right. and this guy is like, he's like what are you afraid of? i'm like there's like murderers there and he looks at and he goes the only difference between me and them is i missed. but this guy was like very smart and very thoughtful and like he had shot at people, you know. he was in the drug trade, and he had shot at people and he freely

admitted everything he did, and i really believe that he was intelligent enough and, you know, just ambitious enough and hard working enough, like it was prison. it didn't matter if the boxes were stacked perfectly. i didn't care. and he was like, no, that's not right. smith, come on, senator, like change it around. you got to do it the right way. like he had pride in his work inside of prison. he wanted to do a great job. i think he would be fine on the outside, and i think even though, sure, there was guys that were already plotting their next crime, there were some of those, you know. but that was not the norm, and maybe we had a different experience. most of the guys wanted to fly straight. >> that was my experience as well. one thing i would say about jeff's story, and this is a perfect thing, if you said, well, jeff, you knew what you were doing. you know, you knew what the penalty was if you said you weren't involved in that meeting so you got what you deserved.

he had no idea what the penalty was. they'll say what were you thinking? he wasn't thinking. he made a decision on the spur of the moment without thinking everything through. that's what people do. those are called mistakes and bad judgment and same thing with me. i mean, i fought my charges -- they were lobbying charges, essentially bribery charges not because i disagreed with the government's theory that i gave people tickets to events or took them out to lunches or dinners and ultimately hoped they would do something for my clients. that was called lobbying. it was what was my intent. did i have a criminal intent to trade those things sort of in a one for one basis on them and i would have done anything to stay home with my daughters. i would have pled guilty in a second if i could have done that, but i was going to have to incriminate against others, testify against people i worked with, members of congress who did i not believe was guilty and i wasn't going do it. that's my sob story and i live with it. i went to prison and i didn't seek any sympathy from people

who were serving much longer sentences for similar mistakes. so i would say this, i was not happy i was involved in the system i was involved. i gave them the fat to pinch. so i'll take my lumps. i was sort of raised that way. you asked for it, watch who you hang out with. but the people there, again, they didn't think about their conduct, and if you had said, well, the penalty for this crime was five or the penalty is for 25, it would not have altered their behavior because they weren't thinking doing cost/benefit analysis, so i wish sort of this -- growing field of behavioral economics would inform more of our policymaking here because there are things you can do to sort of prime people to make better decisions or to at least punish them in ways that responds. restorative justice. make the person who sold drugs be accountable, go to a clinic where people are really trying to get off drugs. let them see the repercussions of what their drug trafficking did. don't let them sit in a cell for

ten years where they have no face-to-face contact with that. there's other things we can do, but i think the idea of these people made mistakes, they're not innocent. i agree when -- people would say system is racist. every black guy said the system is racist. i'm like did you do it? yeah, i did. okay, let's go play basketball. they all thought i was an idiot that i had gone to trial. and so what matters is not whether they're guilty. the question is, is the punishment proportional to what they did? and i don't think it is in a lot of cases, and that's what we need to re-evaluate. are we safer because of the punishments we're doling out. >> i think this has been a great discussion. the most cheerful thing to me is that there are programs on smaller scales that have worked. this has now been taken up across the ideological spectrum. criminal justice reform broadly including prison reform.

i'd like to go on forever but we're incapable of doing that. i will say jeff's book is for sale outside. they take credit card. he'll sign it for you, and just a quick note on this. when i got the book and i still have the dust jacket on and it's got jeff's picture on the front, my 5-year-old said what he says about every person he sees in the newspaper, is that your friend? what's the book about? it's about when he went to prison. and all my older kids gathered around and they thought that was a really interesting story and it was an informative them for me to talk about. my oldest asked if she could read it. i said no. don't buy it for your 7-year-old child yet. but it was -- i thought that was a really interesting thing, that that exposure to that, it's something in the bible we read about, but you're supposed to visit and care about the imprisoned but it was a new thing. so i see it getting picked up across the spectrum. i hope these little solutions on the local level can bubble up,

but i want to -- >> speaking of little kids in the book, my 4-year-old son every time we're out in public, he's very gregarious, probably got the politician in him, he just walks around to everyone and he says, hi, have you read dada went to prison? >> thank you, guys, all for coming. [ applause ] on the next washington journal, sulma arias on an injunction blocking president obama's executive action preventing the deportation of 5

million illegal immigrants in the u.s. then tom ridge looks at new threats to the u.s., including threats to cyber ware and the electrical grid. and after that, dr. thomas freeden discusses a reported 25% increase in multi-state food-borne outbreaks in the past few years. plus your phone calls, facebook comments and tweets. washington jurge live at 7:00 eastern on c-span. all of you, thank you for your support and to the kids for just saying no. thank you. [cheers and applause] >> my hope is that the women of the future will feel truly free to follow whatever paths their talents and their natures point to. >> i think they thought that the

white house was so glamorous, and your role was so, what you did was glamorous, what you did was glamorous, and all they saw was the parties and the meet being people and, you know, and i've got to tell you, i never worked harder in my life. >> nancy reagan served as long-time political partner, ferocious protector and ultimately as caretaker for president ronald reagan. an involved first lady. she was active with key staff decisions, policy-making and campaigning. she made drug use her signature initiative with her "just say no" campaign. nancy reagan, this sunday night on first ladies. influence and image, examining the public and private lives of the women who filled the position of first lady and their influence on the presidency. from martha washington to michelle obama.

sunday at 8:00 eastern on american history tv, on c-span 3. all campaign long, c-span takes you on the road to the white house. unfiltered access to the candidates, at town hall meetings, news conferences, rallies and speeches. we're taking your comments on twitter, facebook and

>> good afternoon. i'm nancy, whichley, chairman

and ceo of the foundation and i'm delighted to welcome you today to our briefing on transforming health care to drive value. we have an exceptional page of speak -- panel of speakers. they're all on at the forefront of driving -- the way we deliver care, consume car, and pay for care. copy of their presentations will be posted on our web site, after the program. we have an impressive audience and want to invite you into the discussion as well. so at the conclusion of all of the speaker's presentations, if you want to fill out the blue card in your folder and hand them off, we'll be looking for them and bringing them up here so you can address the speakers. the first speaker is well known to all of you, dr. patrick

conway. he is someone who has a lot of titles. he is the deputy principal administrator, the deputy administrator of innovation and quality, and the chief medical officer of cms. dr. conway is responsible for overseaing and improving the program that serves millions of americans who access health care through medicare, medicaid, chip, and the marketplace, also known as the exchanges. he personifies excellence in public service, brings a unique background as a physician, a strategy consultant and a researcher to his position. and he brings a talent, real talent for problem solving and a tremendous passion for finding and increasing the quality and value of the healthcare system. he has received the secretary's highest award for distinguished service, and with that, let's welcome pat conway. [applause]

>> thank you, nancy, i all apologize, i am stoic my voice is a little odd and i have to leave after i talk. i try not to do that but was told i need be back in baltimore for some things. so, i -- i've been chief medical officer for five years, cms is like dog years to feels like 35. and true story. when our our communication folks the other day said patrick you need a new picture. you look older then when you started. i went home and asked my wife, die need a new picture? she said, yes. so, i will move threw the slides relatively quickly if i can. hmm. perfect. and i'll adhere to the time limit. so if you think.the affordable care act, three major changes,

one, insurance coverage were at the lowest insurance rate in roared history for the united states, another set of data come out yesterday and we'll talk about that today. i will talk about health system tropes formation, delivery system reform, focus thing coasts and quality of care. next slide. this just shows a cbo estimate from 2010 and then looking again at 2015, predicted over $20 billion in cost savings from reduced medical trends. both our own actuary and independent analyses now saying that a portion of this change is due to structural changes in the system and delivery system reform. if you go to the next slide, this is from harlan, who is a hard-core health services researcher. you don't have those people say jaw-dropping results in "the new york times." just to call out a few results from a study over 68 million

beneficiaries, reductions and n mortality from 1999 to 2013, this is also testing me itch don't have my glasses on so this will test to see if i have my slides memorized. reduction mortality, reduction in hospitalizations at a population level so less medicare by-riz being hospitalized even as the population ages and becomes more frail. reduction in cost for inpatient admissions and reduction of hospitalizations in the last six months of life. not on this slide, our own quality measures for cms. over 59% of the measures improved significantly over the last three year so significant improvements in quality across the u.s. next slide. thank you. this just -- we'll test to see if i have to look it's -- our frame for delivery system reform. we talk about incentives, both privateer and consumers, value

based purchasing, alternative pavement models and care delivery, true population health management and also engagement of patients in their care through shared decisionmaking and other means, and then we talk about information, which is transparency about quality and costs of care, but also the right information at the point of care. i'm still a practiceing precision, take caring of children with multiple chronic conditions and that information at the point of care is critically important. next slide. this is a payment framework. you do not need to memorize but was published 18 months ago now. four categories of payment alines with a lot of the private sector folks you'll have for item and from a payment framework released from our learning in action network. category one, fee for a service not link to call the or cast. category two, fee for service with a link to quality or cost.

classic example is hospital based purchasing. category three, alternative payment model built on fee for service, like bundled payments and then category 4, true population based payment to a provider. these are all provider -- youle hear from private payers and others how they're also moving to value based payment. next slide. this president and the secretary announced in january of 2015 specific goals for alternative payment models. this is category three and four, where the provider is accountable for quality and cost of care. 50% by the end of 2018. we settling thing goal for the federal government but we want private sector actors, which you'll hear from today to move in the same direction, private payers, provide efforts, consumers, purchaser groups, employers, et cetera. the second goal was value based payment. at least 85% linked to value by

the end of 2016 and 90% by the end of 2018. we're on track to meet those 2016 goals. we also launched the healthcare payment learning in action network to really partner with the private sector to achieve the goals we have agent eighth of the continue largest pairs, cma and the private payers, over 80% of the population, over 25 states engamed. large employers, over a thousand provider groups. we have a summit that had people representing a huge portion of the u.s. population, really driving to achieve these goals. so if you look the next slide. this is graphically shows the goals. the dark blue -- in 2011 we had zero percent in medicare in alternative pavement model. 20% at the end of 2014, and continue to grow so just graphically shows you the shift you're seeing in payment in the u.s. the last thing i'll say here, my

seven-year-old son has this stat memorized. cms spends approximately a trim dollars a year across all proms. more than $2.5 million a day-more than 100 million an hour. so in the course of this two-hour discussion, 200 million plus. our goal is how do you spend the dollar alleges wisely as possible? how do you partner and catalyze change that improves quality of care for people developed and generates healthier people for our country and it's smarter spending. on the next slide, this just shows our value based payment program. key point here in the middle box, you seek hospitals right now have eight% of payment via readmission and other value based purchasing programs tied to quality and value, physicians and clinicians nine percent for large groups, seven percent some smaller groups. it's a significant amount of payment tied to the quality of care delivered do beneficiaries. on the next slide, i'm now go to out of the innovation center, so

started leading innovation center two and a half years ago, as you know, ten billion over ten years to catalyze new payment and service delivery models to improve quality and lower costs. this lists all of our mother-in-law -- major models. on the next slide, on the accountable care organizations, we have more than 400acos in the medicare shared savings program, almost 8 million beneficiaries in 49 states plus puerto rico, and with our medicare shared savings rules and we're work only another set of rules right now, some of the benchmarking issues which we said publicly we're looking to improve this program over time. i'll talk about some of the results. the other important note here, if you think about medicare, 2% growing in medicare advantage. 20-plus percent in alternative pavement models. you already have a minority of medicare in what was traditional fee for service, and even within

free true additional fee for service the vast majority of payments was a link to quality and cost. on the next slide, this is our pioneer aco result. first mod toll be certified be the actuary improves quality and lowers costs and we built into the medicare shared savings the learnings from pioneer. the other learning from pioneer, generally people can go in or out of. pioneer, first model out of cmi so i think at that point we were at a different stage. people could only exit. so by definition, the numbers are going to go down over time. every time one exits, it gets a lot of press. we tried to explain this. i've given up trying to explain it well. i'll talk about a next generation model which we think a number of these organizations now are decidings, do they go into track three or stay in pioneer or move to next generation aco. the key opinion is we want an

array of payment models that immediate providers where they are and we have a principal that providers should have choices around the pavement models as long as we're all driving to improve quality and lower costs. dramatic improvement inside quality and patient experience and over $400 million in colls savings. so, successful model that met the bar in lowering and costs. we think there's some key attribute smears got a robust interest. we hope to announce the select entities soon. prospective attributions. know your population. full cappitiation, and you can choose a lower amount. patients, select their aco. voluntary app attribution, the patients says this is my accountable care organization, and then things happen like rebate tooth the beneficiary to stay within network and also enhanced care coordination

service it because the provider knows they're part of the network, waivers, think things like telehealth. smoother cash flow and a benchmarking mechanism no longer just historical. actually looks more similar to mid care advantage where you're looking at regional benchmarking approaches. so, on the next slide, this just shows primary carry initiative. i grew up in a small town in texas but i learned how to talk fast. i don't want too take any of the other people's time. so, this is our -- one of our primary care models. partnering with private payers so in seven states and regions, medicaid, medicare, and private payers. coming to the table. we agreed on 13 quality measures, exactly the same. we all are putting in per member ex-per month population bailed payments and ask the provider

another decrease total cost of care. first two year results, one year on the slide. dedecreesed hospitalizations, decreased e.r. visits, high level of quality of care, and i think we are in the evaluation modes for this one but trending in right direction in a positive way and what the future primary care will look like. on the next slide, think an net domestics brings it home. one of the practices, rural, southeast arkansas, they've got teams, four physicians, nurse practitioners, care managers use, the funding to get pharmacists support, social work support, et cetera, using electronic health records to steer patients, using telehealth to monitor patients remotely, doing home visits for frail elderly. the leader of this practice set a few key things. first our patients love it. they don't know all the detail another the finances behind it but they love it. they get called at home. get their medications managed. a clinician sees them in the nursing home they love it.

second, i've been in family practice for over 30 years and finally practicing then way i want to. and third, i never would have done this -- all the payers nut a million dollars in this practice year one, and population payments. they brought down total cost of care 3 million. this investment would have mortgages his house five times over. so i think there's a key lesson here that we need to scale spread but when you invest smartly, set the outcomes you want for patients, for physician, clinician teams can work with patients and i have to the results we want. on the next slide, state inknow vacation work, we have now got 38 states and territories where we said we want you to achieve better care, smarter pending, healthier people, flexible how to get there. we think there's some key components like population health, payment models, work force and flexibility. we have 17 what we call test

states and 21 design states and territories. test states are implementing changes. a few examples, arkansas private payer, redesire primary care. they have baseball insold that is medicaid mothers through one year most natal. a bundle payment with you invest in prenatal care you decrease preliminary indications and are showing results. minnesota is doing accountable health communities, linking the social and public health -- public sector with the clinical care delivery system, vermont is work only all payer aco type concepts, oregon with coordinated care organization. so, really exciting to see the state and local change driven by these models. on the next slide...

>> >> and like i said we will release the first to result soon but we're very excited about this model.

transforming clinical practice we are investing in supporting positions over $650 million investment with 140,000 physicians thank clinician's across all 50 states. to lower cost and improve population in health management. on the next slide the news like decrease seeing hospitalization or increasing appropriate use of care and similar to demonstrate savings. traditionally to run a a model on a number of years

to contemplate to monitor the data monthly and we adjust them. our payment model has been adjusted multiple times. it was a key fundamental tenet to talk about on a college-age or in france to work under way. with beneficiaries for the first time ever to be at the same time as curative care services to improve quality of care and patient experienced and lead to a more efficient health system.

so what can we collectively you do together? focus on better care and healthier spending for the population and that you serve to invest in the quality and data infrastructure to focus on transparency. those plans are a major driver to positive change we want to have a culture of collaboration, a partnership and improvement. it is a three-year journey. but they pursue rubio, banks for having me here today and for listening. [applause]

>> you could see the whole range of things they're doing it duse incredible. well done. now we will hear from andrew one of the most innovative not-for-profit plans in the country. and now widely adopted quality contracts. a key contributor to the successful launch of the of health reform plan. and of last health care reform optimist. to drive positive change in the state of massachusetts.

>> they give florida state this event today. i will share time to speak more slowly. [laughter] you heard about go work with the delivery and this is a reform. if by doing bad and we have doing that we have rigorously studied a model in the nation and actually around the world that they try to think of payment reform.

with those coverage reforms that health insurance levels are a the highest in the nation. in the time it where is hard to ruth talk about. and the result of a architect just do delay because for decades those in the country the progress was held hostage and said the cannot extend coverage so coverage was never expanded. so after the law was passed

massachusetts started to turn their attention with that powerful item that we had was the paper co to say you already are so far ahead but we are behind it could be the most expensive place to deliver health care in the nation. so bad lacrosse's and what could we do is the largest commercial paper in the state to lower cost and improve quality? this is also a time when a patient safety and quality improvement was eating women

time so what we want to do is designed a payments system to approve quality and lower cost. so we hired a consultant. [laughter] tuesday's coordination with the most effective pavement model to come back with the 250 page report to say there is no such model. very disappointing so we had to invent one ourselves. >> we put them in the remand we called it the cave. and here is what they came up with. we decided we had to move away from the system and not

pay for the health but as the primary-care practice to successfully manage a chronic illness was kept out of the hospital. if there were not doing a good job we paid them more isn't that backwards too wanted to change that so we started to establish a budget based on all medical services, medical care prescription drugs, a shared risk model you have to be on the decline being trend for pro 64 daschle a recognize quality measures validated

and to also try to disrupt that adversarial relationship where every area you have a negotiation let's go where rework together so we had a few pioneering plans to table in with groups and over time it is now the standard way to pay for care that now is the standard care. what happened to read 2011 that was such of big jump for word?

pyrrole leaders of massachusetts i will talk about results as the quality is that this is the principal way to contract and not require you to do this. to keep the fee-for-service pavement's extremely low. and on the front page of the major daily newspaper but although i did not intend it this way that there are other in their mental factors as well. as the fever system became less attractive the budget system became more attractive.

this program we want to change the name because with a big success it would have been called blue innovation or blue skies. but it is too late. but the acrid and had already stock it was called the 8qc and is now around the country. but it is the most regulus -- rigorous so a team of researchers had been publishing results on a the aqc annually and consistently if now increases quality in all types of provider groups are succeeding. academic community and the

practices that serve low in kong vulnerable populations to meet the targets these results published luck -- last october in the early years of the studies we have a classic controlled experiment those in the aqc and those that were not as so many were in we had to compare them to other groups outside of massachusetts and by number for compared to the control medical claims spending was a full 10% lower. a similar story of dramatic changes. researchers observed over a number of different domains and there are to hear, while

national numbers stagnated stagnated, our physician practices improved dramatically. some of the aqc group's nine out of 10 diabetics the proposals under control the national average is 70%. that was the early results but when it looked at our products about half of the members are with hmo put the rest is pp of the most dominant form of insurance through the country but weaver getting questions from other plants including the government with the hmo population when they enroll have to choose a primary-care physician. so we spent two years back studying the problem now we

come up with a solution and we announced earlier they were expanding its now those covering to produce 50,000 -- 250,000 are joining the new model. so the you receive the call that the doctor laid out 40% of payments nationally in this alternative model. we're already there in massachusetts 40 percent are under the new models. what have we learned? obviously before i get to the use you have heard about physician leadership, a change of culture having meaningful financial impact

impact, and a long-term investment but i will focus on learning and support. how are we supporting our position to be successful? and what that does to the changing role of health plans like mine. the issue the doctor talked about that is a big barrier i will tell you how we did that then finally how we change the model over time. the first test to do with support we provide our physicians with daily, weekly, monthly, quar terly, a newly reports of other patients are bearing your patient was admitting last night and you may not know that to very detailed

statistics about care patterns from a chronic illness, hospitalization, th ese reports have been designed in collaboration with physicians and they are using them extensively to change care as a result. but it turns out there is a great desire of shared learning so regularly convened groups of our position and practices together you may recognize the noted author and colleague of mine talking about and of life care how that could be improved improved, separate groups medical managers that come together to share learning experiences in and can call their own physician and leaders for communication

and support. these payment models have grown and flowered so well those of the system were excited about that. this is a strength of the blue network nationally so now we have reforms or others around the country putting together a national network of paved reforms. what does this do to plans and providers? most of you know, in the '80s and '90s health plans like ours have intensive care in disease management capabilities because of the delivery system of patients were not getting the connections or the care that they needed on a population health basis they now take

accountability for that management so should a nurse stationed be calling patients to remind them about appointments or talk about relevance? or should that be more logically placed inside the practice themselves? we are working that out. this evolution will change the world. on the issue of retribution i know some of you are policy experts but this is the key question that seems tactical but if reform can working physicians feel they're held accountable for the right population progress remove from hmo where patients choose primary care doctor and their ppi product we have to develop the way to attribute

numbers to accountable groups to work with physicians and other local health plans to improve accuracy and then we did important things. the agreement to physicians to say are the use your positions? that is an important way to validate the model. to give them confidence when we start paying on of budgeted way of population health for members have not chosen a primary-care physician to say these are their patients. but to sustain a model over time we had one interesting innovation to use each

quality measure to drive their share of risk so better quality scores they meant there would repay a smaller share of the cost overruns or fake to keep a larger share of the savings so often the efficiency incentives and quality incentives are separated but we could join them together that innovation has been well-received. you also hear reagan of a about the cacophony of measures that are out there for quality. we have been very focused to narrow those measures from 64 down at 50 and also the next generation once that we are very separate -- excited in the next model our patients reported outcome measures their own experience their functional status, power they doing

emotional health to be rewarding position and practices of some of those measures that patient's care the most about. we wanted to have a learning culture so now we have six or seven years' experience to read know what is working but we know we can get better so we created a model that is flexible to continue to innovate we now have a powerful chassis of collaboration of better performance, higher quality, lower cost in a way that works for patients and caregivers. thank you very much. [applause]

>> para neck speaker is chairman and c0 of florida blue he leads a family of four were thinking companies including the state's largest health plans are being 7 million and provides medicare payment services to 12 other states. is leading the transformation from an insurance company to grow this company with a strong focus on health and wellness and prevention for girl improving quality and value and serves as the chairman. [applause] >> thank you cheer everyone for putting this forum together. doing an outstanding job

about payments i will spend some time talking how payment reform falls into the broader picture of changing the health and health care system in the country because if you step back, looking at the question in front of us as a nation. i don't believe it is a political statement but i believe something we're passionate about that all americans i don't think it is a political statement of where we should be as a country purpleheart we get there is the debate but at the beginning of a health care reform discussion we talk to reforming the delivery system, outpatient access care, insurance and the debate got narrower as the discussion moved for were due to political

factors but let me take you back to a broader picture. our company is a $12 billion operation handling people in florida also medicare payments that is $108 billion of medicare payments in that business unit alone so we have a tremendous amount of data to understand what is happening in the system. as restructured our organization the blue cross blue shield in the state of florida is florida blue robo we created three other one is guide roll hall where read to direct delivery of health care and own a variety of health care assets. died well connect is reduce the retail business to focus

on the consumer how we have delivered health care in the nation and the delivery system because the convenience was to doctor or hospital or somebody other than the patient we are big power to be transformed them to be responsive and guidewell source is the medicare payments that is of a company is structured so we look at the old world and fee-for-service medicine designed for volume the more you do the more you get that is the system we have generated therefore we have much overuse and a lot of spending that is a necessary. to date the new world has much more pavement alignment

and a system that is focused how to utilize the data that we have, the technology, and we look toward the future growth as your truly innovative with partners as we spend more time on what should one organization do versus another? there's a lot of redundant activity and how to refocus on population hall? and more about how do we work together to drive for better results for the people we serve? >> we think about this and much more holistic way how we use data and of the technology to drive through accountable organizations and we have a variety of those across the state of florida.

i understand now refocus around the'' -- the twin cities of florida is a whole other story. you know, miami and jacksonville or to defer universe. [laughter] tampa and orlando are very different places so we have at least five regions that don't act like each other with a different ethnic makeup different history and delivery system on the ground which means we have to be very sensitive to the geographic, cultural, a background needs so our delivery model varies all over the state depending are rarely deliver the service. fisker issue the generation of things we think about

like how to use virtual care. they talk about televisit with the fee-for-service that could mean someone could spend a lot of visits because they have access through the telephone now so you have to be in the world of payment reform for that to make sense so to create efficiency it needs to replace the visit in the office but only because historic feat that is rather provider was paid so you wanted the service you came to the office. we say think about where our kids will be we have the privilege to go to the doctor's office to wait them the exam room to wait to.

may be having that comfortable sealock to sit on the cold table and to see the physician to get a written prescription they have to go to the pharmacy to wait. our kids will not accept that. because everything happens on your smart phones so why should medicine me any different? we talk about most medical happenings will be on the phone with the doctor that transmits your bridles you have the visit they go to the pharmaceutical prescription that you pick up your convenience because the system is built around you and not the delivery system more will happen that way and. paper co talking wrote the

different regions of the state's, we literally have what is going on the same geography with differences because the system is so large and fragmented it will not consolidate overnight but insteps. primary-care alignment replacing with hospitals intermediate bubbles of care and to looking at a variety of ways to deliver care. we have the first model that is the firm of south america we believe the first time u.s. company contract with the non u.s. firm to deliver health care in the united states. think about south florida.

increasingly people from south america have landed on our shores living in south florida. this is what they know very well precontracted with them to deliver medical clinics. they're building seven more over the next 18 months. culturally significant and sensitive in the community the first is 80% hispanic population everyone speaks spanish. a clinic belt with the understanding the family matters greatly in that culture and often they come to the clinic together. rebuilt waiting areas that facilitate that and one-stop shopping thinking of primary care, emergency care

mammograms, mri or specialty services solemn place because in south america there used to getting all care in one place a lot of people from other cultures will like the idea of one-stop shopping everything in a single place? and you see the doctor in 60 minutes from when you enter the state -- the site. if you need follow-up care retry to do that immediately it is dramatically different care. remember the patient a different way to think about care. we are excited about the clinics and they have been warmly received. the next one is guidewell

emergency medical. why would reduce that? is the emergency place - - room the place you really want to get your care? honestly? [laughter] they are not built around a patient, do not deliver for the patient, of so we built across the street from the hospital because it is admitting multiple of the number of the people that should have been following very rich in zero visits many consider it a front door to the hospital and as a way to fill the beds. many people should not be filling those beds but get the care they need, but quickly, high quality and going home. we created this facility to do just that and it is resonating parts of the patients a quality

care, well delivered, a creek and i am satisfied. we're disrupting what the hospitals are doing by putting the facilities in place. to allied health care eight organization if you follow there is an organization that did a very, very good out reach model and sold their organization and now is the alignment health care we have created contracts with them to take care of the chronically ill patients in concert with primary-care physicians. if you're running back practice with chronically ill all seniors you work in concert because of the intensity and obeys folks

are very oriented to a that ended is a partnership model so we will do a better job for our seniors. when you look at the size of the state of florida towards being a 20 million population we're already the third largest date in the nation we have to do more to reduce debt to patients centered homes 700,000 patients today are taken care of in the alternative care model so we're on the path to the targets laid out a short while ago. retail centers.

think of the insurance plan or insurance company, for a minute suspend her you think of the insurance company. we said we will make it a health solutions company and one calling card is the retail center look at this facility we have 18 of these across the state of florida. so what happens? think of the affordable care act you can buy individual insurance but you could also walk in with your claim that has not been resolved and we will resolve that. people say insurance companies are hard to get a hold of the we put ourselves on the front line to walk again to resolve this face-to-face. we will teach you how to use the online tools people

assume and then they think the customer will know how to use it even sophisticated people say can you teach me? we will walk you through so know before you go you can go online to see what the service cost, and know what is service cost, and know what is covered and how much your piece will be purple one of the great questions is daiwa to know in advance my responsibility. we teach you how to do that. the next is care consultants. held the role this programs that are tailored to the individual through consultation through the things you should be emphasizing 71 of those entities could be used.

last year 350,000 unique number of visits. before an insurance company building on the skyline but now we in gauge our members each and every day. customer satisfaction is 92% that is the number to think about what your insurance company? go to care consultants, 97% satisfaction. last year the blue cross blue shield association award for the highest number retention level in the nation because they either have encountered the space are has contacted us face to face or they know that they can. we also talk to the mayor

and the civic leaders in each community to say what would you like this to be to serve your community? read your reading program in orlando literally a of letters -- literacy program the kids come and to leave with a backpack flooded love books and but that is another issue. have a need it to engage to see the hero's read to them. >> you get yourself with the help solutions company. >> yes there are financial

model. >> yes there is the head minister did focus that is all captured on this slide but help is much bigger than health care or being engaged with people proactively to talk about staying healthy in the first place and what drives that is literacy, the ability to go to a school that has a gm program we advocate for those because our mission of help as much broader than the payment on the back and. so we have been a partner outside of orlando. funding partners were johnson & johnson, a ge medical, florida a blue

guidewell as the founding partners. this is to now has the innovation center. >> newt to defend the ability to work, are prayerfully and a dash of the expense to the marketplace and to convene discussions around the issues like how to resolve the primary care shortage? integrated teams can make that happen but what are the best models? one of the things we know when rigo to tallahassee they have a huge agenda and how can they possibly know

enough and route we will be doing as we convene we will bring legislators to the forum to learn about the issues in greater detail. >> so we see our mission as broad, a huge stakeholder to drive the system to change the quality and innovation. [applause] >> that was very inspiring to think about. and try to find the solutions to get us there. now we will turn chiru who

who has just returned from his honeymoon of weapon interesting background includes medicine and finance. a leading conservative change agent and is sought after presidential campaign an adviser in praising marco rubio as previously a vice mitt romney and rick perry a principal author of the apothecary, a frequent commentator on numerous television shows. [applause] >> i really enjoyed what they had to say it is inspiring to see with people focused on improving quality and delivery of care.

has ben difficult to prove but the a great work that both of your doing. but i will talk about a different issue of the high price prescription drugs. this has spent a concern for decades and what i want to to argue today one of the challenges it is seen as ideological or partisan issue and i say it shouldn't be it is important for both parties to put their heads together to think about ways to tackle this problem it has been difficult to prove expanding coverage improves health but innovation and prescription drugs does.

just book of the cholesterol lowering drugs to reduce evidence of a heart attack at a fraction of what we spend on conventional health coverage. the more we can do to expand at an affordable price makes a huge difference to the access to quality health care and i should make the disclosure i am revising senator rubio but please do not associate these views with the senator he would get very mad at me. [laughter] there are too over simplifications that have

dominated the debate about prescription in drug pricing in the united states. the first is it is all about greed because of for-profit companies are greedy and they are exploiting the fact we don't have price controls were other government measures to prevent profiteering and the poster child for this right now the ceo as recently profiled for increasing the price of an old drug used to treat toxoplasmosis. but here is what is important to think about if he is the reason why they're so expensive than car companies are it theoretically a greedy.

so what makes them lessor board banned drug companies? why don't we need price controls? widow seemed to be a battle there just as motivated as any other drug company. why have price is gone up so much? or are there other economic factors that play? >> it is important to understand we talk about the last full months but the new treatment for hepatitis c you can see the dark blue band is the increase the prescription in drug spending last year due to new drugs mostly multiple sclerosis and the price

increases for the drug is already on the market often five-to-10 years. and that is a bigger driver in the new innovative drugs. it is the older ones where they choose to air charge more but the example is egregious and exceptional but a very common practice for drug companies to raise the prices that have been on the market for many years. the other theory is that innovation is expensive and why we have to charge will be charged. mark sector berg is laughing at that theory because his product doesn't cost anything to use it as a user.

google search engine cost nothing to use it on say i have to charge to $1,000 otherwise i cannot find innovation. you'll never hear a google or facebook to say that so why isn't that pharmaceutical companies argue that high prices are necessary for innovation? in fact, in most sectors it is low prices that drive innovation. the whole point is that hot most innovation happens at the bottom of the japanese car companies came here they did not compete for the luxury market but the most affordable car like the honda. as they would gain market share they would move up now

they make acura and did the idea of the lexus but first they found out to deliver the high quality car at the low price then moved up after that. so that isn't happening as much in pharmaceuticals. take another case. you could say it is software, internet companies were if that is different. what about apple? they cost more and evolved over time. so volved over time. so is hard to believe that the first was only eight to years ago then added 320 by

480 screen and it cost $599. the most recent premiere was launched with 128 gigs of memory so 16 times the amount of 13 and a half times the resolution and cost 27% less than the original. what was the last time you heard of a new drug that costs 27% less than of the standard of care? by that standard is has failed to deliver value and innovation at a scale we

receive from their retail technology industry. hearing is an example. and peter is discussing the evolution a truly innovative drug that was the harbinger that we now experience party in a that targets the molecular defect and cares leukemia. at the end of the of life it more than doubled when it was charging when it was launched despite the fact to

other similar drugs launched over that timeframe including a drug that was manufactured. historically there will say i will raise their price of my older drug to meet the new drug less-expensive so the insurers have the incentive to move the people of the older drug then if that goes off everybody is on the new drug and companies have been using that technique to extend the life of their franchises. it is perfectly legal and insurance companies are going along with that but that is the reason why you see the older drugs go up over time if apple said the i pawed from 2,001 they will

charge to a half times for that today and 2001? we would think they were crazy but this is what happens in the pharmaceutical industry. this isn't because of greed or innovation actually because federal policy has distorted the way we pay for it used prescription drugs in such a way that those don't apply to prescription and drugs. the most important thing 2.0 is this isn't a matter of affordability for people who need them. misspent $2 trillion a year in government spending and

the big part is we subsidize the cost of health coverage through medicaid a andretti care program but also to the tax exclusion the value of which is just as large on medicaid or medicare so if you include the lost revenue from the employer tax exclusion and add that to medicare and medicaid we're talking about $2 trillion of subsidies every year. is it any surprise that providers charge a lot no ring the consumer comes from

those consumers? i have simplified their data health care and everything else. the blue bar is defense, or bridges to know where, unemployment benefits , their bread is health care. and their rubio a significant crisis their prescription and drugs are a part of that and it can be avoided. so the point i want to make is better is the assumption is that you shouldn't mess with the way we pay for prescription and drugs in america today it is buying

is a free-market capitalist system but it is not it is not a free-market system with a 10 year old drug costs to and a half more than it did 15 years ago when it doesn't increase the value to the patient. free markets work by delivering better product and a lower price with more quality overtime and and we should be holding the pharmaceutical companies to that standard one of the biggest reasons don't have a free market today is retold pay for this stuff directly is the biggest driver because consumers want affordable product and they demand it it is not they don't buy it companies have a huge economic incentive to deliver those products at a

lower price point with more quality. what we don't talk about is a regulatory mandate that is the president for the health care system the aca requires that insurance companies cover branded drugs regardless of they are more effective than generic alternatives products are required to cover and there may be cases where that is separate it is better for a fraction of the cost to lower premiums to rationalize their formularies where they should.

. . obvious that the clinical value is there. where it is, great, but it is not always. the 2nd very, very important area is that it is extremely difficult to develop innovative new drugs. the fda has gradually layered on more and more requirements to the point where it now costs an

average of $2.6 billion to watch in a drug if you incorporate all the times drugs failed and development for every one that succeeds. there is also is also the fact that of course, there are patents. the patent extends typically on average about ten years. it does mean there is a monopoly and that can be a barrier to competition because it is otherwise so difficult to develop. when the free market is allowed to work it actually works very well. one thing we don't spend enough time thinking about and talking about is the fact that for all of the complaints about the high price of branded prescription drugs, the

united states leads the world and the percentage of prescriptions that are actually generic because of a visionary law passed in 1984 right representative waxman senator hatch drug companies in the united states have much broader access to the patient pool once a drug goes off. cholesterol drugs went off patent.patent. generic drugs came in and took over that market at a fraction of the cost. it cost less to manufacture most generic drugs and it does a bottle of water or can of coke. that is a major driver of value our system compared to our european countries. the idea of substituting their products for older branding drugs is much more restricted by regulation. today 90 percent of all prescriptions in the us upper inexpensive generic drugs. it is importantit is important to understand in context, while we are concerned about the high price of branded drugs the

price of generic drugs is very low and there is a lot more success in the united states for that issue. and insurance companies are getting smaller about -- getting smarter about delivering generic drugs to patients by steering them -- steering them to cost effective drugs. so what can we do to improve where we are? as you know, hillary clinton has performed -- proposed drug pricing to tackle this problem. her proposal would make the problem worse in a lot of ways. it was further subsidize the insurance coverage of pharmaceuticals in a way that would leave drug companies this accountable for the economic value of their drug.

it was shortened the patent life of pharmaceuticals in a way that will make it harder to develop innovative new drugs, and some of the things like importing drugs in canada won't have much of an effect because it's 110th the size of the us plan drug companies are much more sophisticated now and restricting a majority of those countries that you can't import drugs. so even if you could, it would not have that much impact on the us market. and importantly, she did nothing on fda reform, which is one of the principal problems that drives up the cost of healthcare come and nothing on regulatory reform which outside of fda reform is extremely important problem. so what can we do to actually solve this problem? it is simple. let's do more to reduce the barriers to entry for knew computers, competitors, reform the fda we have as you know in the house. that is a modest but good step to actually removing some of the barriers, the competitive entrance and

disease areas. we can level the playing field between branded drugs with patents and insurance companies. today insurance companies are barred by regulation from mending together to negotiate with drug companies. private insurers. if you don't have my drugs, but this guy does, you will lose your patients so they feel pressure to cover drug when the economic value is not there. that companies band together and you would get a much more economically rational result and can do more to allow people to shop for their own health coverage because that gives health plans more of an incentive to rationalize there drug form not just with drugs but with doctors and hospitals, two to deliver that insurance product at a cock to come in a cost-effective way which will lead to all sorts of downstream effects of plan design innovation and better value for patients. if you want to hear more about my thoughts on this you can download these various documents and with that i thank you for your time and look forward to your questions. [applause] >> well, that was thought-provoking.

just to be clear, we take no positions on the election or any of these items. we like to have different perspectives in the room, and that was excellent and thought-provoking and now we are going to hear from hoover reinhardt who may have some different ideas. again,ideas. again, we like to have all of the ideas out there. so now it is my pleasure to introduce the james madison professor of political economy at princeton university. he is recognized as one of the nation's leading authorities on health care economics. he has served on numerous prestigious commissions, advisory boards, and editorial boards, and you can see more about his background in the packet if you look at his

biography. he is a prolific author and original thinker with prolific author and original thinker with a gift of making rigorous, complex, economic analysis accessible to students and all of us here. he informs public policy and public speaker and blogger for the new york times, forbes, andtimes, forbes, and gemma. talk about a wide range of outlets there. he is the longest-serving advisory board member, and i have had had the pleasure of working with them for over 22 years. it is a warm welcome that i offer. [applause] >> thank you for this warm introduction. sheila says she likes to have stuck in the garden party. i said, that is why god created me. my slides up? i can see them. this. okay. so if you think about innovation and health care, there are two areas. one is biomedical research, the one that was just being

discussed, and the other i would call operations research. every industry have -- has not. health services research which is aimed at improving the efficiency and patient safety with which healthcare is delivered, including drugs, and these are quite different areas. on the biomedical side the advances have been breathtaking. even more breathtaking. we could have more. the viagra pill last 50 years, for example, or something like that, but the reason we are the leaders, and the us is the leader in this field, as we have great scientists, and if we do not grow them we import them. we have a flourishing venture capitol market such as no other country has, and