t defining moments in american policing history that i've seen since i've been in this arena. and probably in the last 40 or 50 years. we have the opportunity and, quite frankly, the obligation to redefine policing in a people are talking about a cultural shift. we have to start with what is the role of police in a democratic society. i'm going to borrow a phrase from dr. king on how peace is not just the absence of war, it's the presence of justice. public safety cannot just be the absence of crime, it must also include the presence of justice. so we have to change what we want the role to be for policing. so mass incarceration, statistical drops in crime cannot be the priority of public safety or law enforcement. so what the department of justice has for us to really work on this one is my office focuses specifically on community policing. we offer services for police departments to take a look at their operations, their assessments, to work with the community, to evaluate, to provide progress reports.

we provide training. we deal with issues of implicit bias , which is a huge issue of why people do what they do and getting to understand the impact of it. we have the department of justice has a civil rights division which everyone is aware of with pattern of practice investigations, most recently the agreement in cleveland. the ferguson report. we have a lot of services. and i think the way we respond to crisis, the way we respond to what's happening in the country is, one, to provide assistance to communities. i think the attorney general said it best that we cannot federalize local law enforcement, and that's not the intent. there's a reason why would -- why we created these 16,000 departments, it was about local control. but we can help set up standards by which the 16,000 agencies should be able to follow. and we should assure that whether it's two officers or 20,000, that they are engaging in constitutional policing and that the impact to the community is the same. we can also provide training and guidance. we can identify best practices and working with the community to

ensure that we are doing it the right way. i also point to in december of last year the president put together the 21st century task force on policing. and he wanted to, really wanted this task force to identify a couple things, address a couple questions, how do we build trust between the communities and the police department and how we do so that we still can assure we have the kind of public safety that we all deserve. and for and for a about three months, four months the group worked and there's a report out we just released in may that identifies 60 concrete recommendations on how to proceed forward. and what i would strongly recommend as community leaders, civil rights leaders, you know, teachers, community members, law enforcement is to really look at those 60 recommendations. and they range from looking at and independent prosecutors to civilian oversight to implicit training to hiring to diversity. those core things that we know would get to the systems that

are at play. you know, too often in this country we make the debate about good officers and bad officers and that does come into play. we need to hire right cops to do the job effectively. but as someone said earlier, maybe one of speakers, it's not just about good and bad officers. we actually have systems that will make sure good officers have bad outcomes despite their best behavior. the system was, in fact, designed to have the outcome which is the disparate incarceration of young men of color. we're still operating in some systems that were used to enforce jim crow leas, policies -- jim crow laws policies and -- and practices that exist today. and so a part of this is changing the culture of the organization, changing the operational systems, questioning how we provide public safety services, questioning how we fight crime. and, you know, making sure you're empowered to ask your department and your cities the right question about what they're engaged in and use that task force report as a report card. are you engaging in these following things, and if not turn to the department of justice and get some assistance

or follow the better examples. . i'm going to close with this we , have a very unique opportunity to transform police anything this country. i'm watching in my own generation now a new civil rights movement, and it's an amazing thing to see, you know? just a couple weekends ago, last weekend my son graduated from high school, and he just got accepted to college. he's going to be going to northwestern. now, i've been a cop for 30 years, i was chief for 8, now i have a pretty good title at department of justice but i still have the same fear as every black man here and black mother that when my son goes to this college, what is he going to encounter? what happens when he walks down the street when he goes into chicago? it's not an indictment on law enforcement. i was one for 30 years, it's the most noble profession, and i respect it across the board. but we have a lot of things to fix, and we -- this is the time to do it. so i would really say that we really need to push forward to to find ways to to wring the community together -- to the bring the community together, make the

civil rights movement not against the police, but with the police. i'm seeing chiefs walking on demonstration lines i'm seeing police departments starting to recognize, and i'm hearing police unions recognizing that we need to improve the relationships. so i would just ask that we come together, that we basically not make it a -- [inaudible] it's easy to point blame, but can we get in that circle of change together and really advance public safety for this country that it doesn't make a difference what color my son is, that the only thing i should be worried about when he goes to college is his grades and whether or not he wants to bring me a grandchild too soon. [applause] [laughter] >> wow. ms. garza, i'd like to pick up on something director davis referred to, the democratization of justice. can we talk a little bit about how we can do a better job incorporating the voices of most impacted voices of community members genuinely into this debate? how can we -- what do you suggest we do to make that happen? >> absolutely. so i think the first thing that's really important is to answer this question that mr. davis put forward which is what is the purpose and intent of policing.

and you know, from one perspective you could say that the purpose and intent of policing is to solve problems, right? and from another perspective you could say that the purpose and intent of policing is to, is to incarcerate people, right? to criminalize, to strip people of their rights and also to punish. and i think what we're seeing right now is a movement that's trying to push more towards the question of how do we solve problems and are police mess for that. that's an honest question. i think the other thing that's really important is to understand that to deal with the question of criminalization we also have to deal with all of the issues that lead to it. is so someone earlier said that you know, poverty is inextricably connected to this question of criminalization. and so if we're going to address that, then we need to put the most impacted voices of folks who are in poverty who are

searching for jobs who are without food, who are being criminalized for being poor. at the center of the conversation. and part a of that is by having those folks shape what the policies, practices and systems should look like because nobody knows better how to shift the trend of criminalization than those who were criminalized. the final thing that i'll just put in the center of the table is not only do we need to center those voices, but we need to put folks who have been directly impacted by the system that we're facing in positions of power. so it's not enough to have task forces, it's not enough to have a person who can speak to these issues. fulks need to be able to make decisions that impact our lives. and until we're able to do that we're not going to see a lot of the shifts that we desire, and that's why in the opening remarks we heard, right, that it doesn't actually matter what the face looks like if the agenda's the same. so let's make sure that the people who want to move a more

progressive agenda are in a position to be able to make those decisions. >> thank you very much. reverend brown, given your work in north baltimore, i want to talk to you a little bit about or ask you, um, you know, ms. garza referred to how we can sort of get the voices of the most impacted into the conversation. what issues are you seeing on the ground in your work that aren't being translated into effective policy either at state level or at the federal level to reform our criminal justice system? >> well, i think alicea hit it on the head when she talked about and referenced the power arrangement and who actually is determining where our resources go. i think that we have to really just sit -- [inaudible] as my jesuit brothers and sisters

would say, we've got to lean into that discomfort and look at the ways in which the power brokers and stakeholders are often times those who are not directly affected by the institutional racism that is manifested in local communities. writes? and so i'm having a deja vu moment a little bit. i'm not a old guy, but i studied history. and after the watts uprising in the '60s, some of these same kinds of settings happened, and the same kind of report was produced that spoke to some of the same issues -- and i look forward to reading your report. it's 500 pages, i will get to it at some point. but some of the same issues were addressed in the 1960's. when harlem went up, some of the same reports and recommendations happened. so when we talk about what we need and how to bring them into the conversation, i would say the conversation is already happening, it's just not happening here. it is happening in the local commitments and the barbershops, beauty salons and local communities where people are providing expert analysis on not only the problem, but also the

solutions, and i have a hunch -- i don't know if this is true or not -- but i have a hunch that the solutions that people are coming forth with in, like gilmore homes in west baltimore and east baltimore are the kinds of solutions that make us uncomfortable because it may mean us moving out of spaces of privilege and rendering space to others who can speak best and move the most on these issues. and so what does that look like in baltimore? in baltimore right now what that looks like is not only the legislative work we're doing as part of a wonderful organization called baltimore united for change, it's a group of social justice organizations with a long and strong track record of working on these issues from the legislative advocacy to op-eds and everything else. community organizing, etc. but in addition to banging on the system as i'm terming it right now, in addition to banging on the system in terms of going to annapolis and getting legislation passed and etc., we also have to build some power. and that is the piece that i don't -- as i study history, i

don't see that piece put forward as strongly, right? and so with the report and commission that came out after watts, it was what can we do for them? and the report and commission that came after harlem, what can we do for them, right? and so it's this assumption that at the base of it if we just provide more, then they'll calm down writes? -- right? and i think also on the other side of that i think is people who are directly affected by these issues of institutional racism and the like also have a tendency sometimes to recline and say, okay, now that the uprising is done, let's wait for the experts to come in and fix it, right? i think we have to remember why, why did i even get invited to the center for american progress in the first place? it's because young people in baltimore said enough is enough, and all of the avenues that you have set up to to deal with the issues that plague us are not working, and so we're going to do things our way. and then i get an invite to a wonderful panel. [laughter]

rights? or alicia gets an invite -- speaking at wonderful conferences, right? so i think remembering what got us here, right, how do we continue to organize the build for power in such a way that continues to have us at tables of negotiation and not at the kiddie table n. my family, i've got country roots in my family. my dad's side is from north carolina, my mama's side from virginia, and in our family coming up when we had big family gatherings, there was the adult table and the kiddie table, and i was so excited when i graduated from the kiddie table to the adult table. at the kiddie table, you had no right to say anything about what the adults were speaking about right? and so we looked over there, but if we even acted like we heard 'em, they would -- move over, mind your business or whatever. and so we graduated to the adult table.

why am i saying that? i'm saying that because i believe that organizing on the ground in baltimore and oakland, new york, and what have you, that it's time to turn over the kiddie table and go to the adult , table, move the adults away, this is the agenda we need to set up. baltimore looks like a speeding ourselves. one in four people in baltimore live in a food desert. and until we in the midst of the uprising said, you know what? we need to start doing some of this stuff on our own because we can't wait for the benebraska -- the benevolence of others to come and save us in the midst of our trauma. so we started feeding ourselves and creating a food system that connected churches with farmers, with colleges and universities and i personally was driving -- alicia was on my church bus -- i personally was driving food around the city along with our partners and our colleagues and feeding ourselves. and at the pennsylvania and north avenue, and i'm a pastor

too, like pastor mike, and so i feel -- i need to shut down in a minute, i feel my third point coming. quickly, i'll just say what we saw was we started to create the systems that we needed. and so near the pennsylvania and north avenue, i was watching on cnn and whatever else, the corner stores were affected to the degree that entire neighborhoods were starving because those corner stores were affected, right? and that's criminal even before all that went down. it's criminal that entire neighborhoods are relying on corner stores to eat, right? and so midst of the uprising that picture crystallized, and it was urgent for us to move forward on feeding ourselves. not only that but also on canvassing our own communities. so we are not calling 911 for everything. let us move into spaces where we develop the training, skills necessary and just be neighbors and sisters and brothers again so that we can help to engage

some of the issues that might lead to interpersonal violence so that we don't even have to call 911 for everything. and so you saw bloods and crips and black guerrilla family and preachers and imams, sisters and brothers marching together through the streets, just checking in on family members. you ok? even in the midst of the curfew we are checking with each other. basically in a nutshell, in addition to banging on the system, in addition to going to the white house and moving forward on legislation to ban the box, etc., etc., i think it is a mistake for those who are post directly affected by these issues to recline and wait for others to do it. we have to continue to build for power economically, socially and politically so that we can get to that adult table and say no more will we rely on the benevolence of a system that has an appetite for our destruction to decide our destiny. no more. [applause] >> taliban i you really feel.

quite still make me follow that. >> won't. we're all going to follow this in talking to a one. number of you about this panel we talked a little bit about this bipartisan moment that we are all observing or experiencing, and i want to ask each one of you to answer this question. what, if any, opportunities do you see for solving the problems you all identified? getting off, getting to the adult table pushing through in communities to take care of the predicates to entering the criminal justice system, resolving implicit bias, getting to issues of reducing barriers to folks who have records? what opportunities do you see to resoing all of those issues and more many this bipartisan moment in the state level, at the federal level. i will start with the stars of. >> well, firstly, incarceration is incredibly expensive, and one thing that i think democrats and republicans can agree on is that it's an incredible waste of

money. and certainly not an effective use of resources given all of the things that we are trying to make sure has resources and funding. so that seems like an opportunity to me. i have to be honest though, when we talk about the bipartisan moment, we have to be very conscious of the fact that a incarceration is also an industry and a business. >> yes. >> and so until we remove the profit motive from putting people in cages and keeping them there for years and years and years and years and years and then having them under state surveillance for years and years and years, we're not going to make much progress even in a bipartisan moment. so that's something i think we need to be paying attention to moving forward. but again, i do think this question of how do we more effectively use our resources to promote the social good as opposed to continue to further social ills is a wonderful opportunity. >> you know, in terms of the postconviction barriers that we

see, you know, we're seeing red states and governors in red states passing laws issuing executive orders. and, alicia is right, a lot of it is from this notion that this doesn't make economic sense, what we're doing. you know, when i'm in rooms in d.c., there are people from sort of all spectrums that are there because either it costs too much, it offends their religious sensibilities, they're worried about the civil rights implications, you know, from sort of all spectrums of the political sphere. and they're coming together at this moment and understanding that we've got to give people a second chance. and what i think is so important about that is what the reverend was talking about. that in and of itself is something that can put formerly incarcerated people right at the center of the solution. because once that first person gets a second chance in an employer situation and people know their story and they

understand that this person has made a mistake, has accepted responsibility and has changed their lives, or, quite frankly they learned that maybe they , didn't make a mistake, that the white kid two neighborhoods down didn't make as well. but they didn't get the chance that that kid -- who looked like i did as a teenager -- god. and that will start to be a way to open up the conversation about the racial systems that we have in this country that give some people a chance and other people not a chance. and about the never ending human capacity for redemption and to turn one's life around when that's needed. and i think that's one of the most tremendous tools. so we come at it with these public policy levers, but what's really going to make a difference is when people get that chance and other people have their eyes open and their hearts open. and they understand that things aren't black and white, simple answers, yes or no, right and wrong. and that there's a lot of

complexity to it. so for me, one of the things that's most exciting about this moment is the opportunity for people to really learn from other people who have gone through the system, about just how unfair and unjust it is no matter how it is that you got there. >> wow. i think a lot of the roots of this is in something i will call us versus them. the us versus them is that there are -- we're talking about closing prisons, right? there's an economic engine that is driven by prisons in different communities, especially in upstate new york where i'm from. so they want to take away jobs from us by closing our prisons and we can't let them do that. inside the prisons there's this tension between us and them. they want to keep us locked up so they are the enemy. and in our churches they don't want to hear what thus sayeth the lord, so they are the enemy,

or they don't go to church, so they are the enemy, or they don't open a bible, they open a , -- they open a carotid, so they are the enemy. they wear blue uniforms and carry guns, and they are on our streets, and they want to victimize us. and they are on streets, so they're committing crimes, and they are a danger to us because we may not go home at the end of the day because something one of them does to us. and we have to, some of us have to live on this dangerous precipice of being us and them at the same time. i'm us and them at the same time. i'm the us because i progressed to the point where i have a nice job, and i live pretty comfortably. me and my wife make a nice living. and i look at some of them on the corners, and they are an affront to me because they are where i used to be, but they don't see that they can be where i and, and i live on the am. precipice of us versus them because even though i spent nine

years of my life in new york state prisons, my father was a cop for 25 years in new york city. so i went to a place where they put us, and us lived in my house, us was my dad. they were my dad. so we have to start to transcend this difference between the kid table and the adult table and know that the kids have to have a voice because how can the adults properly raise children be they -- if they don't know what the children need? and how can the children properly relate to the adults if they don't understand the adults point? and we have to stop thinking that people are taking things away from us and realize that it's not an us versus them, because if we really looked in the mirror, if we really dig deep, if we really look within ourselves, we realize that when we look at them, they are us and we are them. and the only way to solve this is to come together at the table of brotherhood. cops aren't my enemy. cops aren't my enemy because

even though i feel nervous and some kind of way when i get pulled over because i drive a nice car in the hood, i still want them because i want them to protect me. and even though that muslim over there has been vilified and demonized by the media as being somebody that's against american values, they are still us because i have muslim brothers and sisters who want their children to go to school just like i do. and correction officers who want their children to go to school just like i do, because there's correction officers' children who go to school with my children. so at the end of it, we're all in this big melting pot that means if we don't start doing something for ourselves, we're all doomed. and we have to stop looking at it as who's trying to take things away and realize that all of us have something to offer, bring everybody to the -- bring everybody to the table and let everybody have a voice. because at the end of the day, i don't care if you're democratic, republican, white, black, young, old, southern, northern, we all want the same things. we all want good schools, we

want an opportunity for prosperity, an opportunity to live better lives, an opportunity for our children to be educated and be safe going to and from wherever they go. we don't want to have to monitor our children at 15 years oold because we're afraid they're going to be shot by somebody who looks like them or because they're afraid of what they've seen in the streets, and they don't know us. so we have to get to know each other. we have to sit down at the table of brotherhood. we have to shake hands. we have with -- we have to hug one another. we have to have uncomfortable conversations. we have to make one another mad. we have to walk away and agree to disagree and not walking away saying i don't want anything to do with them. i may not be comfortable with it, but i have to understand all men are -- and women -- are created equal. and we have to stop that narrative of saying all men are created equal because all men, all women, all children, all black, all white, all christian, all muslim, all formerly incarcerated, gay, straight, lesbian, we're all god's children, and we all have a

place at the table, and we have to fight for one another because if you don't fight for me, then we all lose. [applause] >> one of my professors in seminary, he said i'm a believer and a realist, the two will not -- are not the same. he would often say that. he would push us as preachers to stand and lean into the vision of what we can but not so much that you lose sight of where you are. and i'm so thankful for how the reverend just put forward -- i thought i was preaching. we were in a tent revival for a moment. how he helped to point us to a vision of where we can be in light of where we are. i would just add that what sister alicia has shared, i think, is particularly important as it relates to the realities

of the bible called spiritual wickedness in high places. we had 17 bills in the last maryland general assembly. earlier this year. 17 bills dealing with police accountability and transparency. and my brother love, another member of the coalition, awesome, awesome brother, we're working, going to annapolis from baltimore back and forth over this 90-day period. and as we were building a statewide coalition to get something done, we learned pretty early on that these bills were not moving. in a very candid conversation with one of the leaders of the legislative black caucus in maryland, i said, delegate, we come down here every other day we've got to feed these people, we're bringing folks from baltimore every other day, why can't we get anything done on this legislation? and she said very frankly, she said to me, reverend brown, she said, the police union puts money in all of our campaigns.

>> yes. >> she said, and we can't pass anything if they don't like it. the same thing came back to the fore when not long ago governor larry hogan vetoed legislation that would enfranchise 40,000 people in baltimore alone with the right to vote. and can i just be a little bit weird giving people a second -- with giving people a second chance? i think if we flip that on its head, perhaps it's the people giving the system another chance. perhaps. because when you think about people before they -- black people before they're even born before they're even born having to face hurdles, societal and political hurdles before i even come through the birth canal. we can look at how the tables are stacked in such a way that before i even get here, you're running before i can have my birthday.

and so i think that when you look at the profit motive that you raised, very important point which is why i go back to building for power in local communities. i am thankful for those who are doing the work at the federal level and trying to move things forward there. but i, again, remember watts. major legislation passed shortly before watts went up. and people -- why, we just gave the right to vote, this, that and the other, and why are people still upset? i think a part of that may be because it just takes so long before my day-to-day reality is impacted by something that whoever's in the white house signs. and then, too, when you look at the democratic and republican, in maryland, yes, we have a republican governor right now. but as pastor to mike said earlier, you know, we are a democratic legislature. maryland's supposed to be a progressive state legislatively, politically, etc., nothing

moved. so i think the opportunity is for local communities to continue to build for power, continue to examine questions like what is the role of police and what do we need to feel safe. and then with this question of how can we improve relationships between the police and the community, stop killing black people. stop killing brown people. >> please. >> stop killing trans. stop. let's start there. before we go to how are we going to hold hands and walk into the sunset, and you stop killing us? let's just start there. on the ground in baltimore, it's really not that complicated. stop shooting me. we really can just -- we can shut down the whole conversation, send this back to the bar. stop killing black people, brown people. stop killing, marginalizing, oppressing people. let's start right there and continue. if the onus is always on the community to show up with good

natured, good hearts to extend a hand and a peace branch, i think you are wrong. i think repentance is due for the system that helped to put us in this position right now. it -- this position right now. it is the police, it is the system of policing that must repent, and let's go from there after we get that done. >> -- quite solidly a. >> two things. i'm going to start where the pastor to left off at, and i think we have to be careful -- not to say that he's wrong but i think it would be oversimplistic to simply say stop, right? because if everything stopped today, a lot of the systems we have still involve mass incarceration, bad relationships, and i agree with you about one thing. one of the things we're learning is what happened in some agencies and not all of them is to get reconciliation, the acknowledgment of the role the police have played in oppressing communities of color. so i think there has to be a starting point, i agree with

you. the starting point has to be the acknowledgment, in some cases even the apology that it was the police that enforced jim crow's law, the war on crime that resulted in disparate outcomes the police that have disparities in everything from incarceration to even the use of deadly force. we acknowledge it. it's our policies. even though they're well intended, they have resulted in deteriorating, literally thousands of neighborhoods across this country. then i think we can sit down and have a conversation. i do agree with you, it is hard to talk to somebody you feel is still violating you at the moment they're talking to you. so we have to balance that. i would say with this bipartisan moment, i would really encourage -- especially the empowerment of local leaders, and i agree with having people at the table that have the power. and i would say the best way to have the power is to understand the system so that you can change the right part of the system. and so this is a bipartisan moment. we see that there is a lot of support for issues of sentencing reform because as was just said, it's very expensive to keep people in prison. that's not the only part of the system in which you would want

bipartisanship. just shutting down a system is insufficient. some states are doing justice reinvestment. it's reinvesting billions that we're using in incarceration back into the very community so that they can empower themselves and deal with the true culprit of crime and disorder in our communities which is poverty lack of education, opportunities and a lack of hope, jobs, things of that nature. that money should be reinvested. we have a federal reentry sewer agency group -- interagency group that the administration has started, and they identified something like 30,000, 40,000 barriers to people coming out of prison. just things you would never imagine. when i started the reentry program in california, i learned something that was amazing to me that i didn't know know as a policymaker, and that was a person coming up to me and saying at the time, chief, this guy owes child support, so when he gets out of prison, he doesn't get an id card. he was doomed to come back before he even walked out the

gate. he can't get housing because he's formerly incarcerated. if we're going to inform the system, make sure you understand the system. it has to be about reinvestment. you don't want to federalize the police ndc. in fact, the motto i put in my office right now, our job is to help fill advancement field. the answer to the questions we're looking for are in some communities, either an 18-year-old who lives out there all day, how do you create the venue for them to succeed? that is the challenge i think local leaders like here at table have to grapple with to get there. but i just want to make sure we don't over celebrate that. we want bipartisanship, it is occurring. i think we should embrace this moment, but it can't just be one

aspect of the system. it to has to be that system of mass incarceration and not similarly a lot of arrests. it's the back end, and it's everything in between that you would want bipartisanship to support its. >> thank you, director davis. i want to let you answer this last question. you touch on recommendations. there are 60 recommendations. where are our local police officers, local police departments supposed to begin in terms of taking next steps to follow the recommendations of your tax force? >> one is to actually recognize that the recommendations exist and to take the time to read the report and to understand that these are recommendations. and not recommendations of what we can do for you, because it's not -- these are recommendations for the local law enforcement communities to do themselves. i think the second part is to acknowledge that there is a dramatic need for change. that there has, something has to change and to understand why there is so much unrest and why people are so upset with the

police. the third part, and i think this is the critical part, is the acknowledgment of why we're standing here right now and that the demonstrations are not just people who want to defy the law, it is an expression of people's frustration from being disenfranchised and being oppressed for many generations. the generational mistrust is exploding. once the agencies understand that, then the idea would be to then sit down with the community. of the recommendations we have i think, the task force was brilliant at shifting it that we didn't say here's what you should do, because once again that's an edict, and we're basically telling communities a what to do. for example, civilian oversight. they recommended that the core principles of civilian oversight should be there, that this checks and balance requires that. it still requires local leaders, community members and local government to decide what's the best venue, format and structure for you, and it's not a one size -- for them, and it's not a one-size-fits-all. so i would really think the

police departments should, one read it, should do an evaluation to see what recommendations they're implementing, which ones they are not. the community should do the same thing, and they should sit down together and figure out which ones are applicable to their community and implement it. we're putting grants out there to incentivize it, to support it, additional research to identify those best practices, and i think -- and we're going to keep trying to help at the federal level, but the keyword is help, because i agree with everyone here it has to be, you know, some of these issues have to be dealt with at the local level. >> thank you very much. we are going to open it up for questions. by the way, ms. garza has to make a flight back to, back home. so thank her. [applause] pastor mike's going to join our panel for the q&a.

go right ahead. >> my question is this, you can't get locking two million people up and it not be bipartisan. so you all are saying this is a bipartisan moment right now. white supremacy and racism is bipartisan. so to term it as this is a special moment for my freedom when my being locked up is not that? and by the way, i'm the person that helped coin the term ban the box. so at a certain point when we talk about banning the box, for the most part unless we change it to fair chance and allow other people to move it forward, we won't even get credit for our own voice. it will be taken over and usurped by educated people that doesn't necessarily mean that it will empower anybody. so when y'all talk about ban the box and you don't attribute it to a body of people that actually been fighting for other -- for over a decade to get equal rights, then you're actually doing us a disservice because it will disempower us.

>> i agree. and a lot of the work we've done around ban the box new york even with the city council and the picot network, one of my critiques of this is that ban the box is a nice gesture that starts a conversation and needs to go further. it's not a be all end all because there's ways around ban the box. and in most legislations that i've read, there's not enough teeth to really punish employers more not following the mandate. so it's really just the beginning, it's one of those symbolic victories that we need to fight for, that we need to continue to fight for which starts a larger conversation which reverberates into further policy change into exactly what you're talking about. >> if i could ad one thing to -- add one thing to that, i watched him when i was in east colorado, -- palo alto

basically, knock on a thousand , doors, hit the street, all of us do the work to come up with that and start with whether it was oakland or berkeley, city by city, going to council meetings and doing it. and it goes to what the previous panel's talked about, about the movement and local people making things happen. that does start to dissipate as it starts rising and starts getting to people with big titles. if we keep our eye on the ball that this movement, i still say this bipartisan moment because there are policies on all sides of the aisle that have contributed to the incarceration of especially the disparate impact, but it's going to take that same bipartisan movement to end it. i think we keep our eye on the ball that it's usually those that are engaged in the battle those that, as someone said, are the receiving end of the service, the lack thereof or even to presentation that has -- even the oppression that has some of the solutions. we can't forget that. and you're right, as we get fancy titles and all the things that go with it, we sit at the white house and things like that, we have to remember where this stuff comes from, who was the creator of it. so i think that's a very good reminder for us as we go about our days and our meetings not to forget where

this is coming from, quite frankly. >> thank you. i am jackie zimmerman, i'm that the department of education, but i'm not here representing the department, i am here for my own learning. mr. davis regarding the recommendations to police departments around country, what if their response is something like, held no? for example, and i make -- and i am asking about the consequences. for example, the southern poverty law center has uncovered in florida that because of the zero tolerance policy in schools if a child as young as eight years old forgets his or her belt on their uniform, they get taken out of school, they get put in adult prisons, 23 hours a

day solitary confinement. the parents lose the right to their child. what are the consequences for that from the federal level or any level? >> so the consequences of not implementing the recommendations at the federal level, there are none. the consequences for violating the constitution could lead to activities we've seen and things like cleveland, ferguson. but those are extreme levels. what i would ask is those recommendations, a lot of the lessons learned goes back to what people are saying. the consequences for not doing good policing, the greatest consequence is the community. not me in d.c. they should be worried about the empowering community that tells that mayor that you're not engaged in effective policing, community policing, and so we get to hold you accountable through the electoral process, through accountability. because, you know, the system is

policing is local. but although policing is local public safety's national. so we do have a role in helping and guiding and providing best practices. but to be very candid, the role of holding people accountable for the implementation of that is limited, and i don't want to miss sell it. we can incentivize, we can encourage, we can lift up great examples of best practices, but if the chief says, man, i'm not doing that nonsense, they can do what, the person holding that chief accountable has got to be that local community that is empowered to say, hold it, i know this is better practice because i've talked to experts on the ground doing it, why aren't you doing this is, i think, the greatest accountability. outside of that we have to wait to where there's violations, but then it means just victims, and you now have powder kegs potentially all over the country just waiting for a single incident to ignite because people are that frustrated. >> this speaks to reverend brown's point of why we have to build our own power.

to hold systems accountable. because the truth of the matter is, you know people will go as , far as you allow them to go. we have to make it so consequential for them to be able to pull that kind of stuff off, this is why the young people in ferguson, in baltimore, in new york, oakland, all across the country, why we pour out into the streets, why we pour out into the highways. we want to make it so uncomfortable for people to do business as usual until you are willing to change your practice. and it's an appeal also to our philanthropy and other wealthy folks that we need you all to help resource the building of power in communities to be able to counteract the power apparatus as it presently exists. that is always well funded. always well entrenched, always very -- [inaudible] be able to

build very powerful response that makes sure that if we can't get the accountability from the federal government, then the people will bring accountability in a way that is undeniable, and that, i think, has to be a part of our work, organizing the power to actually bring accountability to the local level. >> my name is -- [inaudible] i'm from youngstown, ohio. my question is within all of this that we have going on with mass incarceration, no one has mentioned the profiteering aspect and what we need to do with those corporations. corporations don't die. there like vampires. and another thing, we -- so with the collateral sanctions, we have collateral sanctions in place in every state with the department of corrections that give employers guidelines to

hiring. say, for instance, i came home i've been home 22 years, and my charges says that i can work as a social worker. i have my degrees. i got educated, but i can't use this degrees, that's crazy. but how are we going to reinforce these laws and these policies that we with the power now that we know that we have power, how are we going to enforce those laws? we need something else to guarantee the stability that we build for ourselves. >> look, you know, i'm a lawyer by training, i can help guide legislatures in how to draft the best band of for the box law possible, remove barriers, but there's only so far that's going to go because as people have said, there's ways employers find to get around everything all the time. i won't sit up here and be pollyanna and tell you differently. i think it gets back to the underlying point about building power to where it is so

intolerable that people just demand justice and won't put up with it anymore. but, you know, to sort of get into another area that i know cap is very big on, campaign finance reform has to be part of this. because if the prison complex industry can keep pumping money into campaign after campaign after campaign for people that are running on all sides of the tickets, there's a tremendous motive there to listen to that money that goes into the coffers as opposed to the people who are demonstrating in the streets. so we have to be honest about what the supreme court has done to our country as a whole on all of the kind of issues that we care about in terms of the power that the wealthy corporations and the wealthy in general have to really dictate how easy it is for our elected officials to vote against the overwhelming interests of their constituents. >> so -- and i appreciate your

vampire comment. [laughter] because dracula showed up in baltimore too. when when mr. martin o'malley was the governor of the state, he was promoting and pushing a $104 million you to jail. and our coalition, our groups were fighting against that, and we were ultimately successful in shutting that down. now we have a republican governor who has breathed new life into the same plan with lower price tag. now he wants to renovate and build a $30 million youth jail so here we are having deja vu all over again. one democratic governor, now republican -- now a republican governor. the baltimore sun reported so far during the baltimore uprising that the city has lost $20 million. it was only after that happened that the business class, nonprofits, nonprofit industrial complex and the like, they got a higher consciousness when they had a lower bottom line, right? and so building for power in addition to creating alternative

food systems also means looking at other ways so that when we get to -- when we build our own table or go visit other people's tables, we can negotiate from a position of strength as opposed to saying can you please do for me. so in baltimore, april 5, 2016 is the next democratic primary election. so we're organizing now so that when that democratic primary election happens in less than about 11 months now, we'll be able to effectuate our desires from the local communities because we've built up our own capacity and not depending on think tanks and other groups to do for us. >> and the research is important. if we know there are corporations out here who are the draculas, maybe we need to start a dracula campaign. we need to expose them. make them public. because many of this under the cover of night, most folks don't

know that a lot of our fortune 500 corporations are actually profiting off of private prison labor and other forms of legalized slavery, quote unquote. and i think we can shame them publicly in a way that will at least create some kind of public accountability, and we need to do the same thing thing with our elected officials. in the state of california, our governor has taken lots of money from the private industry, private prison industry, and we had to make make -- we had to make that known. and we believe that just because you claim to be a ally of our communities don't mean you get a free pass. if you're engaging in activity that is counter in some of our young folks say revolutionary, dare i say immoral or just plain wrong, then we have the responsibility to make it known. and if they want to continue in

the behavior, then we all have another opportunity to hold them accountable through our voting to where we shop and support etc. we -- >> we have time for one more question. >> good morning. i am the president and founder of the coalition for change. we represent federal employees present and former, who are dealing with race discrimination and retaliation in federal government. and my question is to mr. davis with the department of justice. you know when ferguson happened and michael brown was killed and when baltimore happened and freddie gray was killed, everybody was looking for department of justice to intercede. my question is given the climate of retaliation within the department of justice where the u.s. marshals, black marshals marshals, black marshals have filed in civil court class action and they're pending another one at the eeoc, anyone can google it. he had a 25-year-long lawsuit against the u.s. marshal service after he whistle blowed and told how they were targeting black

neighborhoods. my question is what is doj doing to change the culture internally for those persons who speak out against injustice, who are trying to safeguard the public like those persons in ferguson and etc. that is the question, and i also would submit to you that you support congressman elijah coming's bill on the hill you talked about transparency. that's what we need to safeguard civil servants who speak out and say there's a problem here. >> i'm going to let director davis respond. >> yeah, i mean, other than -- i'm sorry, your name again? tonya, i mean, you're familiar with the departments policies on whistleblowing and actually whether the inspector general or -- there's a lot of options for people to deal with issues of retaliation against whiting blowers, so -- whistleblowers so i'm not in a position to speak

to, quite frankly, the u.s. marshals' service or the lawsuits filed so i'm at a disadvantage other than as a principal, a component. i know the it is our continue wall -- our continual conversation at the justice department to insure that federal employees are protected, that they're respected, that their voice is heard, that you have to protect the whistle blowing because this is how you identify corruption inefficiencies, ineffectiveness. so i think what i would say more so than to regurgitate policies is just to really reinforce and encourage employees to take advantage of all the protections in a venue they have in reporting. there are a lot of options there, but i am going to talk about the marshals service. i can give you my card later and if there's a follow-up i can do for you, i will. but i'm at a disadvantage to answer 5:00 the -- answer about the marshals service. >> i'm going to have to bring this to a close. i want to thank our panel, and ms. garza who had to leave, for this very stimulating

>> health officials and economists released the recommendations for -- improving medical health care. after that, george pataki kicking off his presidential campaign and later "washington journal." >> this summer book tv will cover book festivals. we are live in new york city where the public -- publishing industry showcases their upcoming books.

near the end of june,/annual roosevelt -- watch for the annual roosevelt reading test. the literary event with author interviews and panel discussions. at the beginning of september we're live from the nation's capital. that is a few of the events this summer. >> the bipartisan policy center's task force released recommendations for improving health care in the u.s.. economists focus the report uncritical disease prevention and cost reduction. this is an hour and a half.

ms. loy: good afternoon. welcome everyone to the bipartisan policy center. thank you also much for being here. i am lisel loy. we are delighted to release today the recommendations of the prevention task force, a group of experts from multiple sectors who have brought their collective wisdom to bear on one question -- how can our health system better value prevention to help us achieve our shared goal of better health and lower health care costs? bpc would like to thank all the task force members, some who are here and others who cannot be here today. i also want to thank alice rivlin. and also darshak sanghavi, who provided input along the way and who you will hear from in a moment.

finally, last but not least, the john and laura arnold foundation for their support of this work. prevention is a powerful and underused tool in our health system, with great potential to improve health and reduce spending on treatments and medications for sick people. currently, our system undervalues prevention. we rarely reimbursed for it, and we lack sufficient information on what works at scale particularly on the costs and cost effectiveness of the interventions. i should make clear that when we say prevention, we mean not just clinical prevention like mammograms and immunizations but also diet, activity, weight management programs for example for pre-diabetics.

there are two distinct but mutually reinforcing components of a strategy to better integrate prevention into the nation's approach to health care. first, we need to continue to build the evidence base around what works to improve health and in particular to evaluate the costs of those interventions to help policymakers understand what to invest in. but rather than waiting for a perfect data set to arrive something that we know does not exist, we need a current strategy designed to complement the first components and unfold alongside it starting now. the second component is integration into the existing system using incentives and models of payment structures that reward investment in prevention. the urgency around the second component is this --

we have a moment, an opportunity right now to integrate prevention into the changing delivery system. as our system shifts away from a largely fee-for-service model and toward more value-based integrated models of care focused on quality, prevention emerges not as something nice to have, but an important tool to help deliver better health that lower cost. when we think about operationalizing these ideas one key feature is critical during the task force's deliberations. we need a much more integrated

approach to health, not only health care, and in its 11 recommendations, the task force focused on a number of areas to better link clinic and community. i will touch on two. the task force recommends community demonstrations. to test-drive an example of the more integrated approach to delivering health and how it could be funded over the long term. the task force also recommends cms adopt measures as part of its core set of measures to actuate the resources of multiple sectors. we have real experts on the panel to talk about the recommendations in word detail so let me introduce them and we will proceed. let me introduce alice m.

rivlin. it is a pleasure to introduce alice. she has advised and chaired and co-chaired a number of projects, including this task force, a project on debt reduction. she is currently the director of the health policy center at brookings. she was the omb director from 1994 until 1996. ms. rivlin: i'm delighted to be back at the bipartisan policy center. i get back here fairly often. the reason i get back here is because this is where serious, substantive discussions happen across party lines so that we can actually make progress on doing something, not just shouting at each other from

democratic and republican corners. so i love this place, whatever the subject is. and today's subject is preventing disease. now, everybody thinks that is a good thing, but we are not doing it. or we're not doing it nearly as much as we could. so let's be clear first why preventing disease is such a good thing. why did we all come to listen to this program? i think it is mainly because health is a good thing. that sounds obvious, but health is something people value above all else. our founding fathers probably should probably have talked about the pursuit of health, rather than the pursuit of happiness, because happiness is illusive and it comes and goes and is not measurable. but good health is something that makes everybody's life better. should be value prevention of disease because it saves money?

well, that is a good thing but i think it is kind of a byproduct. darshak will talk about heart disease prevention in a minute. and it is probably true that if you can prevent somebody having a heart attack that would take expensive surgery, you would save money. but that is not the way you want to do it. you want to do it because you do not want to be the patient in that operating room with all the doctors leaning over you trying to fix your heart. diabetes is another example. if we could prevent people going blind or losing limbs because of advanced diabetes, it would probably save money. but that is not the reason to do it. you want to do it says you want to be healthy and not have extreme symptoms or any symptoms of diabetes.

there is of course a danger in overestimating the economic value. those of us who do not die of disease early live longer, and that costs something. but that -- so, we have to be careful not to have the illusion that if we were really good at prevention all of our health costs would go away. we are all going to die of something, eventually. but we aren't really good at prevention. why aren't we doing better at preventing disease? there are three reasons. first, it is really hard because it takes behavioral change changes in diet, exercise, smoking, and substance abuse and we are not very good at doing that ourselves. and the scientific community does not know enough about how to motivate people to change their behavior. we're learning a lot about that. and i think we do know that social norms matter, that group dynamics matters a lot, and we

are learning things that work, but we need to redouble efforts on that. second, society does not make healthy choices easy. you can't have a good diet if you do not live in a neighborhood where you can easily buy fresh food. you don't exercise if you are afraid you will get shot if you walk out your front door. your children do not walk to school if it is a dangerous thing to do. so there is much in our neighborhoods and housing and

the segregation of poorer communities that would help a lot. but the subject mainly on our minds today is the third thing that our health care system is not focused on health. health care providers are not i primarily trained or motivated to keep people healthy and out of the hospital and out of the doctor's office. they are trained to cure disease. so what is it going to take to change that? it is going to take a culture change in the health provider community. it is going to take a workforce change in the health provider community, too.

you actually do not want highly trained surgeons advising -- spending a lot of time advising patients on how to get more exercise or what they ought to eat. you want somebody else who knows more about it and was trained to do that to do it. it is going to take changes in our reward system. and as lisel loy pointed out this is the great moment because we are in the middle of a payment reform revolution in health care. it is moving toward rewarding health care providers for keeping people healthy, but it is not moving very fast, and it is not including the community members, workers, and professionals that could help accomplish that. and it is going to take gradually building our knowledge base so that we know more about what health providers and

communities and others can do that actually works to improve health. that is a large order. but my next task is a good one. it is to introduce one of my very favorite people, dr. darshak sanghavi. darshak and i worked together at the brookings institute. not long enough. he left us to go and be director of the population and preventive health models group at the centers for medicare and medicaid innovation. cmmi is working with providers and communities and everybody they can find to work with in testing new payment and delivery models to achieve the goals we are talking about today. darshak sanghavi has got a special assignment. mr. sanghavi: thank you, a pleasure to be here.

as people have said, everybody agrees an ounce of prevention is worth a pound of cure. so why's it so hard for us to focus on that part of prevention. historical context is useful. 40 years ago, why would people go seek care at hospitals and doctors? things like strep throat appendicitis, car accidents, all these kinds of things that required acute care in a somewhat emergency setting. our payment system evolved in response to that. you think why do we have medicare part a and part b?

part of it is how we decide to pay for care long ago. as the years have gone by, the nature of illness has changed dramatically. we don't have strep throat anymore that is a major public health problem. rheumatic heart disease was a lifelong disabling condition. penicillin, the entirety of the supply was used up treating a single person. we have mastered those challenges since that time. as result, when you go to a hospital or any center today you see a dramatic shift in the types of illnesses that cause us to seek medical care. we do not see children who were disabled by infections in childhood. we had vaccinations. we have dramatically improved traffic safety. we have fewer accidents. the list goes on.

the nature of illness has changed from acute to chronic illness, two things have not kept up. we continue to pay for things in a piecemeal fashion. every time you go in, you get a fee-for-service reimbursement. the way to articulate this is we know the price of everything and we do not know the value of anything. the second thing is that the ways in which we train our most skilled caregivers have not kept up. so you have a situation where, yes, we have highly trained surgeons, subspecialists, and yet when individuals and up seeking acute care, their needs

are extremely complex. they have social, emotional, housing needs, all of these other problems. again, because as a society, we have been so good at dealing with the low hanging fruit we're left with much more complex problems that require greater coordination. so how we move forward from here? we can agree that prevention saves lives and we hope that it also saves money if you value life in a certain way. let's think about how we had incentivized to mention. i work at medicare now, and the lens with which we view the world is one in which we can influence the world by payment. you get what you pay for. every system has evolved to get the results it gets. the ways we pay for care have helped create the system we have today. let's think about prevention. we think that fewer cases of breast cancer is a good thing. how do we incentivize? we pay for mammography.

we could do a better job with doing prevention, the answer is, let's make it easier to pay for the mammogram, let's reduce the co-pay, let's eliminate the co-pay, let's make sure we have universal access to care, public media campaigns that let people know you should get this kind of care. all good things in many ways. does it really incentivize the end result? if they are diagnosed with breast cancer, do we incentivize long-term outcomes in any way? many of us would argue the answer to that question is no. several years ago, those of us said we just pay for these things, we never demanded quality and return, what can we do about that? i'm embarrassed when i am with economists and explaining fundamentally how basic those of us in health care are. the idea was simple. we will pay for performance. in other words, we will ask doctors to click these buttons on the computer to show they are doing mammograms on patients. if you report on that, you get a little bit of a bonus.

if you check blood pressure, you kind of have to now, you click the button and get a little bit of an extra payment. this is after we discovered dna, this is the best we could come up with. and this is like five years ago. it just goes to show we have a great domain in terms of sophistication and how we can use what we understand about incentives to pay for prevention in much smarter ways. and i want to talk about at least one of the ways in which we are trying to move forward now. rather than continuing to pay through the fee for service system -- secretary burwell announced national goals to move for value payments. in many ways this is the fundamental reshaping of how we pay for care. rather than paying for

everything we do, we are now paying for overall cost of care. in other words, we in medicine to some extent, are learning to survive in the confines of having at least some budgetary responsibility. we all have to do that in our daily lives. we are asking us to do that with our health as well. the issue is moving from volume to value, at least in the initial stages, and we are in the very early stages, really incentivizes the short-term win. you want to learn how to do the cardiac bypass surgery better so you can realize the gain in a year or two. you want to focus on how you do joint replacement better, and you look at these big ticket items that give you rapid value. clearly, prevention doesn't -- when you think about when we

talk about reduction in obesity, type 2 diabetes, reduction in depression, mental health, early childhood achievement, all of these things are undervalued through that strategy. the question that we are asking is, how is it we can take the traditional ways and baby steps and move it to actually valuing prevention? i want to announce at least one way we are doing that today, at least one example of how you might think about this issue. this was announced earlier today by secretary burwell in boston at a white house conference on aging. i want to describe it in a little bit more detail. i have two kids. we actually watch "the bachelor," too.

there is method to this madness. why is it that show fails to produce durable marriages long term? that is the long-term end point you are supposedly incentivizing. the answer is simple. what is strongly incentivized is having a lot of viewers. they do not actually care if you like each other or if you have a sustainable relationship. we pay for medical care the same way. we want you to be free of a heart attack long-term, but we incentivize everything around the generation of volume early on. in a sense, we are all in an episode of "the bachelor," and we want to focus people on looking at the end point.

today, we announced them one million parts cardio reduction model. this gives you a view of taking the rhetoric that we care about prevention and value it and how do we make it granular and real. it is this. when you currently go to see your physician or provider nurse practitioner, they get paid a little bit extra if they get your blood pressure under a certain target. it turns out, they get paid a little extra to get your cholesterol to certain level and ask if you are a smoker. that is what we do. that is our national strategy to incentivize cardiovascular prevention. the amazing thing is that people do a relatively good job even with those incentives. as a physician, i think there's a very strong cultural component when you appeal to people's good nature.

we are going to change that. so that instead of incentivizing every little bit, it turns out that right now, for those of you who actually see your doctor the standard of care is that your doctor today, based on the 2013 american heart association guidelines, is supposed to take your age, gender, ethnicity, and a variety of numbers, your blood pressure, whether you are a smoker, and they give you a 10-year score. in other words, we can see into the future and tell you with a high degree of precision, what is your risk of heart attack or stroke. if you have not heard this, this is the standard of care for two years, just think about the fact that that is not happening currently. but that is a very valuable tool, a meaningful number. if somebody said to me, based on your individual profile, and the next 10 years, there is a 30%

chance you're going to have a heart attack or stroke, and here are the things you can do to reduce your heart attack or stroke risk, these are the pros and cons, you can stop smoking you can engage in better diet and exercise, and you and your provider can come up with a plan. what we are going to do is pay for that in medicare. not only that, your provider will be incentivized. they will be paid extra if they reduce the 10-year risk, an absolute reduction in risk across the entire panel of high-risk patients. so this is a new way of thinking about it. we are paying to make sure that you get married, so to speak. we are marrying the incentives with the long-term outcome we care about. and the model itself is one of the largest trials that cms has

ever done of a preventive outcome. we are going to enroll 300,000 medicare beneficiaries. it is a randomized design as well, to give a high degree of data fidelity. at the end of it, it is powered to detect meaningful reductions in heart attack and stroke. ok, that is really great, i will close with this, but i think this notion, how is it that we pay for the long-term outcome that is so far away that we do not know how much it costs? we break it down into things that actually predicted this. let's pay to reduce the risk. this is how we can think about our way of designing payments. it is not a broader structure. they are very good ways to predict what you are risk of hip fracture is, for example. based on your generic profile, you can tell with a reasonably high degree of fidelity what your risk of breast cancer is. wouldn't that be better than saying that all women over the age of 40 should get a mammogram and fighting about that?

or we could break it down to say, risk of suicide. those of the ways in which we can think about this and be successful. this is one way that we are thinking very broadly about how it is we fit in preventive incentives into this broader structure of alternatives payment models. when we are moving from volume to value, this is just one tool we have. i look forward to hearing not only from cms that also from our partners in the public and private sectors that incentivizes quality. i will also say, for those of you who are in the "journal of the medical association," in more detail for those of you interested. thank you for your attention and i look for to more discussion. ms. loy: thank you so much darshak and alice. we will come back for questions.

we are going to shift to our moderated panel discussion. for we do, i want to introduce our panelists. to my left is jeff levi, the executive director of trust for america's health. at tfah, he oversees a range of policy issues. he was appointed by the president to serve as a member of the advisory group on prevention, health promotion and integrative public health. he also teaches health policy and management at g.w. to his left, dr. bill dietz. he was the director of the cdc division of obesity for 16 years and is the mastermind behind the

bright red map of the obesity epidemic. i suspect a number of you in this room are very familiar with it. he is an expert on obesity prevention and he chairs a ran table on obesity solutions at the institute of medicine. at the far end of this group is my boss, bill hoagland. bill is the senior vice president at bpc. he came here from cigna, where he was vice president of public policy. but most of his career was spent

on the hill, where he was director of budget and appropriations for the office of the then senate majority leader bill frist. thank you all so much for being here. jeff, i'm going to start with you. we have talked about high-level framework, big picture models, and i want to go to the real world for a minute. more than probably any of us on the stage here, at least, you have the most experience with a number of the players on the ground who are really seeking to implement some of these experimental and new models of care that integrate clinics and communities. >> this is an exciting

opportunity to see where prevention fits in the health care system but it is always important that we have a good conversation about how we value things and it isn't just about cost-saving but better health outcomes. to measure and prevention isn't just determined by how it would save health care costs. in many cases it can, but it doesn't in all cases. it does bring us better health. i also think what we have seen in examples across the country and many others, a growing recognition in the health care system that in order to achieve the goals about improving health outcome and health value that

you cannot achieve those goals within the four walls of a clinic alone. i would posit that to achieve them clinicians will have to reach outside the clinic because if we're going to change increased physical activity and improve nutrition and reduce stress all of which are factors in heart disease then that cannot just happen within the four walls of the clinic. it is both traditional promotion and community prevention but also a recognition that the need for social support and social services is also critical. they have been undergoing an experiment, they created a care organization for what is the equivalent of their medicaid expansion population they have

looked at the spectrum of needs that a patient has to improve health outcomes and they say it isn't just about accessible health care, though they have made dramatic changes their by making dental care more accessible and creating a sobering centers of people don't use emergency departments or the county jail to sober up. they also look at how well people can access social services recognizing that if those needs are well addressed that demand will go down as well. they have been able to demonstrate cost savings and can reinvest in expanding the nature of the services they have provided.

this is a model that works very well as a county where all of these services are provided by the county and what we're hoping in the report and endorsing this concept of an experiment -- to see whether in different venues this model can be replicated. can we find the leadership, the coalition builder the backbone that brings all of these folks together, can we create the data systems that make it a seamless process whether a social worker or on the health care side that people are getting the things that they need. can we make this sustainable financially? there is risk for the health system in reducing demand for health care because we haven't completely moved to value so how do we help people through that

transition and how do we make sure that the investments made in those things that help reduce demand for health care continue so we can see how much we have saved and now we can reduce how much people are getting. this is one example of that but there are sometimes on that scale, sometimes on the narrow scale. we need to examine those and learn from them. lisel loy: a follow-up on the financing discussion, i think we recognize in this group and we collectively agree that this notion of integration between clinic and community is essential, and essential ingredient. it is not going to happen by accident. at the same time, however, those experiments are not going to have a lifespan beyond a little

experiment if there is not a sustainable financing model. i want to go to our budget at the and of this line, william hoagland. we don't always have a deep discussion around costs. william hoagland always raises cost as an issue and gives us a reality check about, that is an interesting idea, that sounds logical, how in the world are we going to pay for that? what jeff is talking about is multiple sectors all of whom have a shared outcome, whether it is social services, education, housing. those are all different budget pockets within that county. how do we make the math work smp

what is the most promising opportunity to integrate those funding streams and develop a model? william hoagland: oh, lisel. [laughter] first of all, thank you, i guess, for putting me on this panel. i feel out of place with all these experts. let's begin with the fact that i agree that prevention, orientation of prevention, things that darshak sanghavi has outlined. we appropriate the money for an activity that does not result in the benefit until sometime in the future. we wait until you are sick before we go to the hospital, as you say. we not reimbursing for the prevention. most of the prevention programs and have in the federal budget start out by being appropriated,

at the bottom line, these are annually appropriated moneys subject right now to a cap on the total amount of money that can be spent. you don't get the benefit of a reduction in medicare benefits or expenditures or medicaid extended chairs, until sometime in the future and the people doing the appropriations do not get the benefit of doing that. quite frankly, to make this work long term, you have to go back and change the budget process in some way to provide for the decision-makers to be able to see that that we does an investment, like infrastructure or education, is an investment that will return a benefit to the nation, to the community, to the decision-makers. and to do that, not to get too

far out on this, i believe the time has come to change our accounting systems in this country so that we have almost discounted value. the invest the money here, but we can escort on the basis of what the benefits are today. if we can't change the cash based accounting system we have, at least we can make the decision-makers know that that investment, if it is based -- this will get to another issue -- based on hard evidence, that that will return a return on the investment. it would be a way to integrate the prevention into the current decision-making process. lisel loy: alice, do you have a perspective on that? alice m. rivlin: i have a question for jeff. how do we know it is

successful? are they actually reducing prevalence of disease? we have a set of health indicators from the county that's will improve? or better yet, to pick up on darshak sanghavi, doing have a set of long-term probabilities of various -- that could be aggravated? you could then say that we would actually reimburse this county for the things that are shown to improve the indicators. jeffrey levi: have demonstrated improved outcomes and reduced cost.

there are certain aspects of the experiment that are unique which is why in the report we are not talking about taking this out nationally but trying and out in a number of communities because the nature of the health system and if the structure in different communities really varies. i think we are not at that stage yet. i do not think we know enough about it yet. i did not agree know enough about the sustainability of the financing model. i think we need to be careful, before we do that. it is one of the more promising examples. i would also like to add something in terms of what bill was saying. some of this, when you think of this notion of integrating or braiding together various funding streams at the local level, that is less a scoring

issue and more how can federal programs get out of the way of communities who want to be creative? i think that is part of what happened, it was the county government taking the risk and the county runs each of these programs. we don't always have that model in other communities, yet there are communities where people want to come together and say, let's coordinate our health dollars and housing dollars and transportation dollars and so on. and yet the federal reporting requirements make it very hard for communities to come together on that. that is not a budgeting issue. scoring issue is a practical issue of how we can -- not just in health care side -- in other programs across the federal government, get out of the way of these experiments.

lisel loy: to go back to alice's question, we are not yet ready to call for spreading and scaling what is happening. what is a mechanism for taking us to the next level? jeffrey levi: i will get to that in one second. there are other models out there. there are some communities where they are focusing less on the health care side and more on the social services side, or more on the community prevention side. some are doing population wide, some are looking at particular conditions. each of the models are worth testing out to see whether they work or not. i think the answer is cmmi doing a demonstration of this notion so that we can test it in a variety of communities and do the rigorous evaluation that i think is important. that said, doing it under the umbrella of cmmi has the

restriction of looking at improved health outcomes. when you're doing of an integrated approach to both health and community prevention and social services, there are other things we need to be measuring that may be of value but again, getting back to the constraints in some of the scoring requirements, are not necessarily something that cmmi would be measuring. darshak sanghavi: there are multiple layers here. one way to formally the problem is to say that prevention is largely an issue of improving social and economic standing. let's look at problems of homelessness and transportation. i would say, i would challenge people in this room to say, how many of you have had your cardiovascular test? i assume host of you are housed

and have stable health insurance. i've seen you do not have significant mental health issues or substance abuse, or if you do, your functional. how many of you struggled with being overweight or have high blood pressure or have had a colonoscopy when you turn 50. there are 10 full variations across the country in rates of angioplasty and cardio surgery that are not explained by socioeconomic status or access to health care. these are major problems in the way that we deliver care directly, from the clinical system. i think one of the things i don't want to be lost here, yes, we in our group are developing several models that address

social determinants of health. it is also important to think about prevention more broadly. it is not just about shifting value to socioeconomic developments. it is that improvements in quality overall in the health-care care system to make this all better. this is a complex problem. if you struggle with being overweight, ask yourself, is the problem that you do not know? that you do not have access to health care? that you don't understand that a big mac is bad for you? i don't think so. let's look at that level. what is it about the health care system, how do we structure in a way that allows people to be nudged in those areas. those are rich discussions we should also be having. this to add that layer. lisel loy: we're talking about on the ground experiments that

contribute to our understanding of how it can work and to actually roll out a system that integrates either clinic and community, or health and public health, plus other social services. that is where it gets even more complex. i want to switch gears to the research question. the other part of what the task force focused on was a need for better understanding, not just of interventions, but also cost implications of interventions. william dietz brings expertise from both the cdc and government sector. the cdc is thinking about and collecting data on all kinds of things all the time, but also the academic community. i wonder if you would talk about the state of evidence. what we know and what we do not know. there is a sense from detractors that we don't actually know what

works and this is all very terrible, we don't know what works. on the other hand, there is the concern raised about overpromising what we potentially know. like most things, i think we are somewhere in between. you know some things, we don't know everything. we are trying to come up with strategies that allow us to take action in light of that uncertainty. if you talked was a little bit about what we both know and do not know and from an academic or research perspective, what needs to happen to help us better fill in some of those gaps. william dietz: thanks, lisel. it is a pleasure to be here and share the stage with my colleagues. the cdc has a number of activities that relates to the evidence of what works in community-based programs starting with president obama's cep pw program -- ccpw program. there has been a big investment in community-based interventions aimed at chronic diseases, most

notably tobacco use as a risk factor, obesity, and physical activity. that is providing a rich source of information. one of the limitations of those data is the lack of very stringent evaluation of those programs, mostly because there is an investment in developing the program, but not so much in knowing whether the program is working or not. the cdc for years has run a task force on immunity preventative programs. and make recommendations about for example if changes and community promote physical activity. there is an emerging evidence base.

another source for those data comes from the substantial investments and number of foundations around the country have made in community-based programs. early care and education centers, schools, and communities. we were part of a conference of the valuators of those programs. we were looking at which of these were most effective at preventing childhood obesity. most of those programs have proximal data. they know what changes behavior. but knowing whether those behaviors result in a change in the prevalence of obesity is a bigger challenge. some of the critics of these programs have challenged what we call evidence. the standard for clinical programs, or clinical evidence is randomized clinical trials. those are not easy to do in communities. we have to use alternative

sources of data is. a recent report provided a variety of strategies for aggregating that evidence. the other thing that is missing that you alluded to is knowing what the interventions cost. in the field of childhood obesity, that is particularly challenging. you don't see the cost of childhood obesity until 20 or 30 years later. how do you assess cost-effectiveness? there is a program known as choices, and abbreviation for childhood obesity cost-effectiveness studies, in which they had taken 40 different interventions, it is still underway, 40 different interventions aimed at childhood obesity and begun to put costs on the outcomes of those interventions. the metric they have used is the

cost per unit of bmi change, because you cannot really put a financial cost on that. that is one issue. what we have suggested in this report is that intervention studies, both clinical and community level intervention studies, be required to provide the costs of those interventions, so we can begin to get more information not only on what is working, but the process of what is working. that might allow us to compare darshak sanghavi's change with community changes. i also want to come back to the other gap, which i think the emphasis on community programs emphasizes. that is the clinical care and public health are siloed. integration is not an easy matter.

first of all, as jeff has said who pays? had he begin to incorporate a payment system that rewards and community system that is reinforcing the types of strategies that darshak sanghavi is proposing? even if you can reimburse, how do you is sure cross communication between community systems and hospital systems. electronic records are often not entered. how do you ensure munication? -- communication? who does this? the backbone organization that links clinical and community services is trust. a notable person once said that change moves at the speed of

trust. unless we are able to break down those silos tween clinical and community services, and unless we develop a common goal, we are not going to succeed. lisel loy: we at bpc think and talk a lot about decision-makers and what they need to make decisions. decision-makers are making difficult decisions along competing priorities and they need evidence in order to make those in a rational way. to pick up on your point, bill emerging evidence that allows us to understand the context and relative cost of these different interventions, i think it is an extremely important development and helpful to decision-makers. i can't help a transition to one question about the congressional

budget office, because we have a former director of cbo and a former staffer from cbo. a lot of discussion of evidence -- some of the discussion about evidence is targeting decision makers at the congressional budget office who are trying to evaluate the potential costs of a certain intervention. if i could summarize it, it would be something like cbo is important but it is not the only game in town. we wanted to make sure that we talked explicitly and deliberately about what cbo needs to make recommendations to the health. at the same time, congressional budget office and prevention is not the only way to think about the value of prevention could let me ask you, bill, as a budgeteer -- i hope i am not getting fired for asking you

hard questions. [laughter] what do you think is the bottom line in terms of what cbo needs and how should the public health community the thinking about it? william h.: i think you should ask the former director before you ask me. this is going to sound like a bureaucratic response. as a former cbo staffer -- but resources, honestly. resources. i know it is a throwaway, but the need to weigh come as part of this activity -- we met with cbo staff. i was shocked at the number of journal articles they have to go through every week. 1000 journal articles, if you can believe it, just to weigh in. i concluded out of that discussion that what they need

is a watson ibm program to condense, at least narrow it down so they can find out evidence which is replicable scalable at the national level. i know it is a throwaway, but they need resources if they will translate this into actual good evaluation of the policies and forth. i want to pick up on something that jeff said, though -- and bill, too, to some extent. the problem as i see it is prevention is not homogeneous out there in terms of the communities. in some communities, one prevention and intervention will work better than some others. it is very difficult at the national level to press national

policy that can be replicated in terms of the cost estimate. lisel: alice? alice: i would second bill's feeling that the congressional budget office needs more resources to you now you wait the evidence -- to evaluate the evidence, because the evidence on whatever it is -- on health intervention, prevention intervention -- is getting to be voluminous. but that said, what they really need is convincing evidence. and i alluded earlier to some of the enthusiasm for -- who would love to pass a bill that says, for example, we should take available to every county in the country, and there are several thousand of them, resources to do what hennepin county is trying to do.

you could draft such a bill. and eventually it would -- if it got out of committee or even serious consideration in a committee -- get to the cbo and say what with this cost and what would the benefit be? the cost wouldn't be very hard because you would specify what that was to be, when you are going to give all of these counties to do this thing. but what is the benefit? they would be driven back to looking at the county. can we say that spending this money would improve the health of hennepin county? if you can definitively say that, and if you thought you could replicate it in several thousand other counties, then the problem would be simple. but neither is true.

you don't yet have the evidence about hennepin and you aren't sure that what has made it possible for them to at least get a start was the peculiar to hennepin county. that is the dilemma that cbo has to face. i think they do a pretty good jobjeffrey: i think there may be more evidence out there than we are accessing. hundreds of millions of dollars worth of investment in community prevention programs that was evaluated. and those evaluations have not been released. community transformation grants was supposed to be a five-year program and was topped after three years so it is hard to do a full evaluation.

but there was substantial evaluation money put into that. we have yet to see data from those. there is also an obligation on the part of federal agencies who are investing hundreds of millions of dollars of taxpayer dollars and who have been directed to do evaluations to release those evaluations. alice: oh, absolutely. we need to know that. jeffrey: we need to know that. that isn't always the case on the clinical side. we tend to publish clinical results. but we are more open on the public health side. we want to know what works and what didn't work. we learn from those examples. what is wonderful about things like community transformation grants and partnerships to improve community health is that while they have the same targets, communities are taking varied approaches, evidence-informed approaches but various approaches to reflect the needs of their communities.

but if we aren't releasing what we are learning from that, then we keep redesigning new programs in the dark. putting aside cbo's needs, it is just not a wise investment of taxpayer dollars. alice: but it would help cbo to release that. william d.: but waiting for cbo is like waiting for godot. [laughter] how do you settle for community-based data, which is really based on a randomized trial? what is the level of evidence necessary to convince cbo? and back to jeff, i think there are other mechanisms that we are and not to be pursuing at the local level through the

community benefits initiative of hospitals, which we need to wrap in, and there are mechanisms in place through the affordable care act to direct those hospitals to invest in community benefits and do community health needs assessments. likewise, and this is a question for you, it seems to me that more flexibility on the part of medicaid to fund these kind of pilot programs that jeff has described, and certainly the ctg and cppw are implementing, would help to move the field forward. what are the likelihood that that will happen? darshak: you brought up hennepin county. the idea -- very simple at its core which is that you take all of this money that is going to pay for the health care at the state level and you give it to

the organization and you wipe your hands clean and it is their job to do with that. they are the most context patients to deal with and they have been charged with doing that. they have certain unique advantages, that those patients are automatically enrolled in the program. you don't need to find anybody. they are yours. there are specific governmental structures that allow types of data sharing that are not necessarily present in other communities. the other thing is that the state has been very generous. while certain states have materialized, they have not had to pay that back. those are the unique features of that particular program. it makes a lot of sense. i referred to the fact that i was apparent. i have two kids. the one kid i give $10 to come he says that money -- saves that money, and the other kid buys

comic books and is totally not responsible. this is the problem we deal with. freedom is good, we believe that. however, in health care, there are big dollars involved. not all actors can be trusted. if hennepin is so great, why doesn't that exist already? we have medicaid cbo's. incentive already exists. we as a nation and as visions ourselves are still uncomfortable with giving that much freedom away, or freedom without necessarily asking for a lot of accountability in return. how is it that you measure that accountability? we talked about having population health or clinical metrics. for those you go online right now and can go to places for quality of the hospital. real patients often don't feel that the data really gets to what it is they really care about. i would just say that part of the issue is, yes, we want to move the nation -- that is what moving to value-based payments is all about them if you look at how we have lay that out, but we

think it has to be done very deliberately. and although the pace may seem like why don't we just directly passed the resolution to give everybody black granite payments, there is a downside to that. this is one of the reasons why we feel like doing it in a somewhat more studied and deliberate manner is going to be better for most patients. jeffrey: i agree that it is not just a question of throwing money out there and that is not the hennepin model, but it is also inaccurate to say that medicaid patients can do what hennepin is doing already. it brings all sorts of resources to the table that then get better integrated, and your typical medicaid-managed care organization does not have the resources to do it, doesn't have the authority to do it, doesn't have the capacity to do it. that is where it is fundamentally different. lisel: