A lot of areas where we can move forward. Thank you all very much and thanks for having me again. National Governors Association also held assumption on scripture drug abuse Prescription Drug abuse in the u. S. Mary bona also created the Prescription Drug abuse caucus. This is one hour and 20 minutes. If i could have your attention, lets take our seats so that we can get our joint session started. First of all, i am governors Steven Beshear from kentucky. I chair the mga health and Human Services committee. Welcome to all the governors who are here. This is a joint session of the health and Human Services committee and the Homeland Security and Public Safety committee. Joining me is vice chair of our Committee Governor bill haslam of tennessee. Im pleased we been able to come together with Homeland Security and Public Safety committee for todays discussion regarding the nations opioid crisis. I want to thank the leadership of the other committee, governor Rick Schneider of michigan, governor jerry mccall of virginia for partnering with us on this very important topic. The briefing books were sent to governors in advance. The proceedings of this meeting are open to the press and all meeting attendees. Please silence your cell phones. Seated at the table are Committee Legislative directors melinda becker, justin stephens. You can see them after the session if you need copies of the materials or further details about any of the issues that we have discussed today. Before we go into our formal presentations, i want to turn to heather halsted, who is the staff director for the health and Human Services and the Homeland Security and Public Safety committees. Healther and her nga colleagues will provide updates on key federal and state issues. Thank you governor. We made progress on a number of priorities. From the health and Human Services perspective, we abdicated actually for an exception of the we abdicated for extension of the ad vocated for extension of the Childrens Health insurance program. That chip extension maintains existing flexibility and planning levels for states. That was a key area we were able to a college. There were also discussions to reform the Child Welfare system to invest and services that keep children safely out of foster care. At the same time, Homeland Security and Public Safety committee has been working with congress to making an Armed National guard personnel. Currently the house and senate are conferencing their bills. We plan to have a final bill in the fall. The senate bill provision, which would receive additional personnel, prevents further transfer until 2017 be included in that final bill. In addition to National Guard matters, they have been increasing a role in a Cyber Security and greater collaboration with the federal government any private sector. The two main priorities i want to cover from the federal relations perspective. I will pause quickly before any questions before we proceed. Happy to antianything afterwards. I turned to my colleague from practices. The director of our health division. Good morning governors. A brief update as to how the health and Work Division is going. We have had well over 20 very intense projects going on around the country with hundreds of your leadership staff. Two projects i want to highlight. First our medicaid transformation policy academy. Their intensive work with alabama, washington state, and nevada where we are working hand in glove with the states to negotiate broad new plans. These are authorities the states have never had before that will allow governors to have let more flux of the league pay for and deliver services in medicaid. We are in agreement with at least one state and look to negotiate in some cases billions of dollars in upfront investment from the federal government. Its very powerful work. We plan on providing you with a very victorious report in february during the winter meeting january. We will be releasing a roadmap for all states that we are hoping to reach agreements with hhs that will allow you all to use a new process to get to medicaid waivers more quickly. We also are launching our next round of super utilizer work in two days. Its aimed at the highest cost, highest spend medicaid patients. They are spending millions of dollars and have terrible outcomes. That will be for the next year and a half. We are ready did two years and had some pretty impressive results. Prescription drug abuse, opioid agrees, heroin addiction have come to light as very strong components to the reason these folks end up using a lot of these services. Todays discussion is i think very relevant from a cost perspective and equality perspective. We will be able to solve one of the most important issues facing state medicaid budgets. Now we will turn to jeff mcleod. Since 2012, my division has worked in close collaboration with fredericks division. We posted two policy academies in several states. States have passed legislation launched Public Awareness campaign, trained providers on safe and effective prescribing practices. We have put out a few different products. We put out Six Strategies states can adopt to address Prescription Drug abuse. We followed up with some new recommendations. Through evaluations, states can better assess the ask the success. Certainly, the problem of Prescription Drug abuse has been grabbing headlines. Substance abuse in general is a real problem as it relates to the safety and wellbeing of children, especially children in the welfare system. We launched a new policy academy on approving child safety and preventing child fatalities. My division will be working again with frederick and his team to build on the success of the policy academies and the momentum that i think there is nationally on this issue on helping states deal with the rising use of heroin. According to the centers for Disease Control and prevention three out of four new heroin users started on Prescription Drugs. If frederick or i can be helpful, dont hesitate to reach out. Back to you, heather. We will stick around after to answer any questions. Governor beshear, back to you. Lets turn to the topic of todays joint Committee Meeting which is opioid abuse. Its a Major Public Health and safety crisis that affects all of our communities in every one of our state. Because of the rise in Prescription Drug abuse and in heroin abuse, Overdose Deaths now surpassed Motor Vehicle accidents as the leading cause of death in the united states. Heroin deaths have increased especially quickly, nearly tripling between 2010 and 2013. Kentucky has its problems in this area. We have long been plagued with high rates of drug addiction both to prescription painkillers and Illegal Drugs like heroin. Over the last few years, two things have happened that are giving us more hope and confidence in the future. One, we passed and implemented a couple of wide ranging and multipronged programs that attack the problem from every angle, including treatment education, Law Enforcement, and health care. Secondly, what we are finding is that our stakeholders are working together like never before, both inside and outside of our state. In 2012, we passed what we called house bill one, which targeted drug abuse and misuse. We ran a bunch of pill mills out of the state. We required our medical professionals to use our statewide electronic prescription monitoring system. And we allowed for better sharing of records among agencies in kentucky and other states. Earlier this year, this addiction situation is akin to the game of whackamole. You attack it in one direction and it pops up somewhere else. We have been pretty successful in the Prescription Drug abuse area and we have seen tremendous progress. But now, heroin is raising its ugly head and is killing even more people than Prescription Drug abuse did. Earlier this year, we took a similar approach in our legislature on heroin. We passed senate bill 192. Among other things, this bill increased prison sentences for heroin traffickers, but it also helps us identify addicts that can benefit from more treatment than from lengthy prison stays. I think we have all figured out that we cannot incarcerate ourselves out of this problem. We have expanded addiction treatment. We have allowed local option Needle Exchange programs. We established a Good Samaritan provision to encourage friends of overdose victims to call 911 and get help. Last month, i announced the allocation of 10 million for a programs aimed at fighting eight and treating drug abuse, including programs to help inmates, pregnant mothers, improve prosecutions of drug dealers, help Public Advocates drop alternative sentencing plans, and expand Substance Abuse treatment at the local level. Governors all across the country are leading similar efforts to address the opioid crisis, bringing together Law Enforcement, criminal justice professionals, Health Agencies providers, and other Key Stakeholders to develop and implement comprehensive strategies. The health and Human ServicesCommittee Held a session on state efforts to combat Prescription Drug abuse during the 2014 winter nga meeting. The committee has since maintained a focus on Prescription Drug abuse, bringing Lessons Learned from states to inform policymaking at the federal level. At the most recent nga winter meeting, governors approved a new policy that calls on the federal government to work with the states in developing a comprehensive National Response to Prescription Drug abuse. Todays discussion reflects the reality that we are no longer confronting an epidemic of Prescription Drug abuse by itself. But an alarming resurgence of the use of heroin. Recent federal Data Confirms that the link between rising rates of Prescription Drug abuse and heroin abuse go together. Indeed, almost half of those who use heroin also abused or had dependence on prescription opioid painkillers, making them the number one risk factor for heroin use. Next week in kentucky, we expect to hear positive news from an evaluation of our efforts to change the land of Prescription Drug abuse. But we still have a long way to go to fully address the opioid problem and the recent spike in heroin. I look forward to todays discussion and hearing from onal strategies that we might be able to implement in kentucky. Im going to turn out to Governor Snyder and ask if you would like to make some opening remarks and introduce our guest. I want to start by thanking you and your other Committee Members for the great work you have been doing on this or the health and Human Service committee. Its important. So thank you for your effort and your perspective. I also want to recognize my partner in the leadership of the Homeland Security and Public Safety committee. We work well together on a number of issues, including Cyber Security. This is also an issue thats critically important to all of us as governors and citizens. This is a great venue to have a discussion. I want to thank everyone coming today in terms of the other governors, members of the audience, and distinguished panelists. I look forward to learning today and being stronger and better thanks to the knowledge you will share with us. This is a major crisis and that is the attitude we need to take towards opioid abuse whether it be Prescription Drugs or heroine abuse. In michigan, we found it to be a tremendously growing problem. To give you some perspective, as i travel michigan, i often ask people what the Biggest Issue they face. Two sheriffs pointed out their greatest problem was Prescription Drug abuse. Thats the starting point of all of this. We need to do more. I am proud to say last year, we passed a bill dealing with opioid antagonists where we actually have our emf people carrying that with them to address the problem. If you have to use that, its much later than it should be. We need to do more in terms of education, prevention, treatment, and the Public Safety side of this together. Thats why doing a joint meeting is particularly important and i am proud to be here. With that though, lets get to our distinguished panelists and learn from them. I look forward to this because in michigan, i have created a task force this spring that will lead into a legislative and other packages of actions to be taken. This couldnt be more timely in terms of hearing from people who are experts. I am proud to say we have a very distinguished panel. I am pleased to introduce congresswoman mary bono. Among the many a competence during her 15 year congressional career, she founded the congressional Prescription Drug abuse caucus and cochaired the congressional addiction, treatment, and recovery caucus now a principal at a Consulting Firm and cofounder of the collaborative for effective prescription opioid policies congresswoman bono maintains a strong commitment combating Prescription Drug abuse and promoting recovery. Thank you for being with us. Also with us today is dr. Debra houry. Director of the National Injury prevention and control. In that role, she leads the cdcs efforts to advance Public Health approaches to preventing Overdose Deaths, working closely with states to expand the use of effective interventions. Prior to joining cdc in 2014 she served as vice chair and associate professor in the department of emergency medicine at Emory University school of medicine, as well as associate professor at emorys school of Public Health. Thank you for joining us. Finally, i would like to welcome someone from the Law Enforcement community. Retired lieutenant detective patrick glenn, who is a Founding Member of the Norfolk CountyPrescription DrugMonitoring Program and director of the quincy program. In 2013, he received the white house advocacy for action award for bringing Law Enforcement and Public Health together to disrupt the cycle of drug use, crime, and recidivism. Thank you and congratulations for your fine service. Welcome to all our panelists and im looking forward to the discussion. Lets start off with congresswoman bono. Would you start our presentations . Good morning. Its wonderful to be here with all of you and to see my former colleagues. Thank you for testifying before my committee a couple years ago, governor beshear. If i remember, i was extremely kind to you at that time, and i hope you will return the favor to me. [laughter] my gavel was very light that day and im without one now. I want to thank all of you for taking an interest in this topic. Im honored to be here to share with you my thoughts on the opioid crisis. I applaud you for focusing on this academic and i encourage you to throw everything you can it. Countless lives hang in the balance. The hushhush nature of opioid overdose death has for far too long been preventing the serious Public Health issue from receiving the urgent attention it needs. I am here with you today as both a former elected official who spent almost a decade focused on Prescription Drug abuse come a but i am also a passionate parent and family advocate who has personally wrestled with this issue. Like far too many parents my , introduction to this problem started in my own home. As a fulltime working mom, i knew my son was grappling with some issues but i didnt understand what they were. One day, i received a call from my son who said mom, i need your help. I have become addicted to pills. You can imagine how that felt. I still thank god for that call and i consider myself to be one of the lucky ones. I grieve with the many parents who werent as lucky as i was. That phone call was just the beginning of a very tough road for our family and it was a journey that we made public by doing National Television and print interviews. After that, my office and i became somewhat of a beacon for other parents going through either the grief of losing a child or pleading for help. To this day, i credit my son for his courage and compassion for speaking out himself and for allowing me to do the same. I have developed a very passion for our youth and their susceptibility to addiction when they face the powerful drugs we have all seen happening too often. We joined forces to create the Prescription Drug abuse caucus. It continues to grow in numbers. Many solid strategies are emerging to deal with this crisis, and there is not one i have read about that i disagree with. They are widely agreedupon strategies such as the realtime Prescription DrugMonitoring Program, research into personalized medicine, and Good Samaritan laws. I support them all. But i focus my thoughts on a few other things. First, in addition to supporting communitybased education, it cannot be overstated that there is a need for strong messaging from leaders like yourself about the dangers of Prescription Drug abuse. We hear so much about avoiding gluten and cigarettes and artificial sweeteners and more but we are simply not hearing enough about thinking twice before we pop a pill. The medical Community Needs far greater education about the diversion of these powerful drugs as well as the disease of addiction. I know the new terminology, but i cant break away from saying addiction and addict. So forgive me, and i used to interchangeably. I use the to interchangeably. For quite some time, there have been some who have denied any role in the epidemic but that thankfully seems to be changing. Physicians and other providers are on the front lines of this issue. Providers, particularly those who treat a High Percentage of patients suffering from any form of pain, must have the latest treatment died lines, including the use of monitoring tools for high risk patients. Including the use of monitoring tools for high risk patients. Secondly, we need to finally and fully overcome the stigma associated with recovery. Those in recovery need full support from their family, friends, society. Recovery needs to be easily accessible with affordable options for anyone seeking help. The Betty Ford Foundation has a program that has core 12 stands for comprehensive opioid recovery using the 12 steps. I encourage you to look into it. I know from experience that needs to be a part understanding of treating additions. The notion we can get somebody into recap and they will emerge 30 days later fixed or cured is not the reality. It takes seriously hard work and dedication for both the individual and family. If a relapse should occur, it should be seen in the same way we look at the recurring cancer. Its sad but true. It should not be stigmatized and we should reach out to anyone who needs support. That recovery should include doing all we can to promote and establish recovery schools and sober housing for college students. Once a young person can leave rehab, there should be safe and supportive options for them to enter. That support should last a lifetime. I would like to invite each one of you to participate in the unite to face addiction rally. October 4 on the national mall. You can find out more information about it at facingaddiction. Org. I will be there to show my support for anyone in recovery. Recovery deserves celebration, not stigma. The last point i will make concerns the collaborative for effective opioid programs. We call it cpop, the collaborative for effective opioid programs. We are Healthcare Providers treating patients with pain, family members who lost loved one to an overdose death, Law Enforcement, Treatment Centers and medicine manufacturers who are striving to make treatment a safer and tamper resistant. The collaborative seeks to stem abuse. We need an important meeting of the minds in order to advance solutions. I invite each one of you to join us, we could really use your help and support. Each one of you should ask how the many many federal agencies who are charged with controlling drugs could allow this to happen on their watch. The congressional prescription will caucus could really use your support with that. I once saw a really good video about the pill problem in florida. A reporter some that up in a way that really struck me. They went it somewhere similar to this. Imagine that 100 dead dolphins washed up on our beach every day. People would be outraged and demand action. Now imagine that continuing day after day, year after year, but this isnt about dolphins. Its about our kids and families. Imagine them washing up on our beaches. We must throw everything we can at this epidemic. Thank you for listening and i stand ready to answer your questions. Thank you very much for allowing me to speak today. Thank you for your work congresswoman. Its important. Next, lets hear from dr. Houry. Think yall for inviting me here today. This is one of our key priority areas. I would like to mention that for our agency, this is one of our top priority areas. As somebody who has been on the front lines over a decade in an Emergency Department, i have witnessed this epidemic growing and changing. I have seen the patients faces. The work we are doing at the cdc in partnership with you, i know we can make a difference. Im excited to talk with you about that today. In the year 2012, there were 259 million prescriptions for opioids. To put that in perspective, that is enough for every single u. S. Adult to have their own bottle of pills. As we have seen that increase in death, we have seen it quadrupling during that time so with the increase in prescriptions, we have seen an increase in death. Sometimes, pictures tell the story better than words. The picture im about to put up, i want you to watch. Look for your state and watch the changes. Red is not good. You can see the rates spreading across the country. Dark red is the highest. You can really see how this epidemic has spread across the nation. It does impact other areas more than others such as the southwest and appalachian regions. Every state has experienced a significant increase. Earlier this month, cdc released a report on heroin. Its important to realize why we are seeing this increase. Its because of opioid painkillers. People who are abusing opioid painkillers are 40 times more likely to be addicted to heroin. If you think about it, it makes a lot of sense. It has the same effect on the brain, so people that can no longer access opioid prescriptions will look for something that is easier to obtain or even cheaper. By focusing on opioid prescribing, we can impact the heroin epidemic. There are often consequences. As seen earlier this year in indiana and in stock county, the hiv epidemic, 170 individuals newly diagnosed with hiv because they were injecting opioid prescriptions. Although this is an extreme example, it can happen in any community in the united states. States are poised to respond to this and must be ready to respond. I wouldnt be here if i didnt think we can make a difference. I am very optimistic that we have the tools we need to have an impact to really curb this epidemic. We did this for car crashes. Overdoses have now exceeded car crash deaths. Thats because overdoses are going up but we have also seen car crash deaths go down. This was a concerted effort, working with different agencies. The cdc will use the same approach we use on for that for opioids. By monitoring the problem, looking for where those high Risk Communities are, what are the risks and protective factors we need to identify those most at risk and identify a set of interventions and take them to the state level and share best practices across state. I am very excited that next month, we will be announcing our Prescription DrugOverdose Prevention for states program. It builds off a Pilot Program we had this past year. 16 states will be receiving 750,000 or more for the next four years. We will be working closely with these states to improve their Prescription DrugMonitoring Program so they are easier to use, more realtime, and will work with Health Care Systems in those states whether it be the Medicaid Program or around guidelines to make sure things are implemented for safe prescribing. What we learned from the pilot year is to have flexibility for states. We have built in a Rapid Response project so states can target specific communities, do a communication campaign, or enact surveillance. Our hope is to be able to make this a national program. We are excited to have the opportunity this upcoming year to work with these 16 states directly. We know this is the right approach. If you look at statebased interventions, we have seen that when new york requires prescribers to use a Monitoring Program, there has been a 75 decrease. In florida, when they began to regulate pill mills, they saw a 50 decrease in opioid deaths. We will also develop chronic pain opioid prescribing guidelines which will be targeted for primary care physicians. This will give doctors tools to know when it is appropriate to prescribe these medications and when its not and how to do it in a safe and effective way. What can we all do with this . I think there is a lot. We are already seeing a lot of these great practices. One is to promote best practices in opioid prescribing states. I know some states such as oregon has already been implementing this through medicaid providers and arkansas has been working in the Emergency Departments. When our guidelines come out in 2016, it would be fantastic if states would use these in their state Medicaid Programs, workmens comp. Programs, or other Health Care Systems. In addition, encourage authorities to stop the work for prescribers, whether it be the state medical board or Law Enforcement. Finally, really improve well informed opiate prescribing by making Prescription DrugMonitoring Programs easier to use. Again, as someone who has had to use one, there is a long way that we can do to make them more userfriendly and more effective. You can work in your states to do that. I look forward to having further discussion with you at the end of this panel. Below is my Contact Information so we can talk about how to reach out to your states directly. Thank you. Gov. Beshear thank you, doctor. Now, lieutenant glenn. Lt. Glenn thank you, and it is an honor to be here. I bring greetings because back in 2009 i believe we took the bull by the horns and came out to say that we had an epidemic in the city of quincy. I can describe exactly what we did with that and how it blends into what is happening today. What we ended up doing is we refocused and took a humanistic approach. We did change some of the terminology, and it was difficult to do. In the past we would call a person junkie, abuser, etc. And we arrested them. We changed it from junkie to family member, we personalized it. We go back and forth with the terminology, i know. With overdose, it is a poisoning, it has an adverse affect on the body. Hopefully we can get the person to recovery. We do not think everyone is going into treatment, but as i said from the beginning, in order to go into treatment, they have to be alive. That is what we try to do in the Law Enforcement field, get the person to be Emergency Department for treatment. We came up with this prevention treatment, much as the governor spoke of. Yes, we are out there arresting, we are not soft on crime. We are arresting the people who are dealers and traffickers. We do have a Good Samaritan law that was admitted to the 12 that was amended in 2012 which prevents the arrest of the individual or someone aiding them in assisting our calling 911 for help. We know in the past that we would show up to the scene and have a dead person sitting in a chair or lying in bed with their identification in hand and there was no one else there. That life could have been saved. We want to try to do that and reduce the fatal overdoses. We collaborate with the parish. I stole that phrase from bill braden. We have to collaborate in this issue. We have seen the deaths in the streets now. We collaborate with the department of Public Health in massachusetts outreach programs, Police Officers such as myself other Law Enforcement agencies and administration. We went to the table and spoke. The beauty of that is we went back to the table again and continue to speak and we came up with this program. The department of Public Health allowed us to enter into the Pilot Program, which was the first that allowed Law Enforcement to administer doses. We will show you the results in a few minutes. This is how we work well together. It is the Quincy Police department, the department of Public Health. These people who are overdosing belonged to someone, they are brothers and sisters, mothers and fathers. Some of the statistics you have already seen, so i will go past that. The map that the doctor showed up there, im glad that massachusetts was representated. In 2013, three people died every day in massachusetts as a result of an overdose. I think we will be up to four or five in 2015. That is every day. Some of the results here this is a little crowded, but what i wanted to bring out was the statistics. We started in 2010. We had 47 deaths in the city of quincy. The following year, when we introduced the lifesaving doses of medication on the street we reduced the deaths. The myth that was there that if you are a Substance Abuser you will come to quincy because we have naloxone we have not seen that. In fact, at the time of the flight, we were about 7 repeat clients, meeting that someone reversed more than once. That is a very low percentage. We are very high in the percentage of the reversal, a high 90 on reversals. It was administered to 433 individuals and we have reversed 416. Those are individuals who we gave an option to go into some other treatment. Or at least, we turn them into their family alive. That in itself is amazing. We have gotten a number of telephone calls thinking thinking thanking us for saving a father or mother. A quick story. We have a vigil every year. A woman came up after the vigil and said, you did not read my name off. I said, that means you are alive, thats good. She said, i know. 17 months ago i overdosed and a Quincy Police officer reversed me. I overdosed again about a month after that, and i was reversed. At that point, it was her tipping point. She went into treatment and has been recovering now for 14 months. That is a success, when someone can come up and say that we were able to turn around. I know this is in your material, as far as prescribed by doctors and providers, over 71 came from a family or friend, meaning that there are too many drugs out there in the medicine cabinet, we want to get them out of there. The common risk is obviously the age group. We have a huge influx between 1726, and then mid 40s on up. There are many drugs involved, it is not just heroin. Naloxone will work only with the opiate family. These next two slides are probably our flagship slides. They demonstrate what the opiate does. The simplistic description is it attacks the receptors in the brain until the respiratory system is nonexistent and you die. You are in an overdose stage you are not breathing. Officers are fully trained in delivering naloxone, the brain starts breathing again, we have the reversal. Documentation will be provided for counseling, and so forth. Again, we are not naive to think that everyone goes into counseling, we know that. We have to give them a chance. And every police car, on the side of the Police Cruiser it says protect and serve. We protect and serve all. We hope to get them to the hospital for further treatment. There are two formulas, one is a nasal spray, another is an autoinjector. They are very similar, the same there are two formulas, one is a nasal spray, another is an medication, different loads. There are some samples being passed around. The autoinjector is a very simple, much like the epipen. Im always ask, why do you do it . I go against the grain and say why not . We are all First Responders and if someone was in a diabetic emergency, we would provide some kind of sugar product to them. If someone is in an opiate overdose, its narcan. I never saw the results of this. I never saw the big deal. We are supposed to help citizens. This is our job. Im just a cop. I have seen people overdose and die within families, generation after generation. A lot of good people. This is not just for the addict, the Substance Abuser, there are people who are accidentally selfmedicating and over medicating who this will work for also. That is how we protect our community with one more tool in the box. I want to thank you and leave you with a few thoughts, multidisciplinary approach. This is a disease and not a crime. We do have to Work Together. Theres no doubt about that. I always like to leave on more of an uplifting note. We did have a reversal two years ago, the Boston Red Sox when they won the world series. We were in boston helping them why are you laughing . [laughter] we were helping with some traffic issues, an individual ran across and said, i know you have naloxone, my girlfriend is overdosing. She was around the corner. They went, administered, and took her to the hospital. That is the perception that the public has now of the police that can help, not just enforce laws. We will enforce laws also. We are looking at this as a disease and have done that since 2009. I think that is great. I do not think we have to worry too much about the world series parade this year in the quincyboston area, but you never know. We are always prepared. Thank you for your time. Gov. Beshear thank you, lieutenant. Lets open things up now for discussion. First, let me call on the vice chairs for any comments or questions that they might have. Chairman . Gov. Mcauliffe thank you all for being here today. I want to thank you mary for your time in congress. You chose where to spend the rest of your life and you chose the commonwealth of virginia, i appreciate that. A good low tax state. I do want to thank you for being here today. In virginia, we have done obviously very similar to what the other states have talked about. A couple of things that we added to our legislation all of our First Responders have access to naloxone, but we also had to protect them civilly so that they could not be sued. It was a hesitancy for many First Responders. The other thing we have called for is a dramatic increase in our drug courts. Obviously we no longer look at this as a lawenforcement issue, we have had to take a holistic approach to it. It is about health care, communities, saving money to keep people out of prison. I want to thank my secretary of Public Safety who is here with us today. He headed up a 32 Member Task Force to address these issues. My question to you, dr. , if you just read the cdc report, it says the increase in heroin is coming from the least likely people that you expect to be heroin additcs. My question is are there Different Things that we need to be doing in intervention earlier and how do we help our Law Enforcement deal with this epidemic . Dr. Houry thank you for the question. I actually read your task force report. For people dealing with heroin as well as opiates, there are three things to focus on. What is stopping them from ever one is stopping them from ever being addicted, that is keeping the substance is off the streets. The slide that the chief showed, a lot of people are getting these medications from family members, that is one way they can access them. Safer prescribing. The second thing, for people already addicted, increase treatment so that we can help them really treat their addiction and get off the drugs. The third thing is naloxone. Making sure that the First Responders have access and the Good Samaritan laws will outlive that. Will really help with that. I think it is important to look at what we can do to stop people from getting that. A lot of them will reverse in overdose, but if we can prevent them from getting to overdose, that is what i think is the ultimate goal around prevention. Thank you. Gov. Haslam i was struck at what you just referred to and the comments of 71 coming from family or friends. Break that down a little more for us. How much is the original prescriber an accomplice . How much is it being taken without them knowing . Tell us more about that, and any other insight as far as things you have done to collect unused descriptions. Prescriptions. Lt. Glynn the prescriptions were legally written. The issue that comes into play sometimes is that people dont always follow the directions on the prescriptions. Usually they stop when they feel better. They put them in the medicine cabinet. Friends come over, they take them out, sometimes pill parties, you have no idea. People will start taking pills out of them. Other than that, there are prescriptions stolen out of medicine cabinets in open homes when Real Estate Agents have agents have open homes. It is one of the Fastest Growing areas of stored prescriptions during those times. Stolen prescriptions during those times. No longer is someone walking out with a flatscreen tv, they go to the medicine cabinet and leave with pills. It is not all of the pharmaceutical companies or the prescriber, it also is selfawareness and taking care of those prescription. The second part of your question on what have we done with access prescriptions excess prescriptions. We have a return box where people can anonymously bring in unused prescriptions and we destroy them. If you dont come during the year we have ongoing programs to assist. The public has been very receptive. We also have senior pickup days where we go round to the Senior Citizen buildings and pick up unused Prescription Drugs also. Gov. Malloy thank you. I just wanted to share a couple of things that we have done in connecticut. We did pass a comprehensive opioid bill that requires the doctor to check on the Computer System before they write a prescription, it is mandatory. Also education requirements on the subject, making sure that opioids that are tamperresistant or consistent with systems to make it less likely that they be abused by that person or subsequent acquirers. We had done our narcan bill in response to ems, local Police Departments and troopers. I can report that as of five days ago in the current year, 36 calls were service, 37 persons receiving medical who were in medical distress. This is just from our state police. In the bill i previously referenced, we are also making a possible for anyone to go to a pharmacist, explain the situation at home with respect to abuse, and receive narcan to have it available to administer themselves in the home setting. We think that will increase the usage. Let me just say something. 3637 states have more people dying of drug overdoses than they do in car accidents. Think how much money we spend in making our roads safe, whether its snow removal, writing tickets, or having troopers on the streets or local police. We do everything we can to prevent those. We are now seeing increases in death as a result of primarily opioid and heroin abuse, and we just have to step up our game. That is what we have tried to do in the state of connecticut. I think this opioid deterrence proposition, where we might have to spend a little more to make sure this is available is an important thing to do. One other thing two other things i would say. We have worked in new england three years in a row, new england governors have worked together to break down some of the problems. What we found is people who doctorshop do it in multiple states. If youre not talking to your neighboring state, youre missing the point. We saw that in particular with respect to hartford and springfield, hartford being one of the largest cities in connecticut and springfield in massachusetts. The number of folks who were doctor shopping in both jurisdictions was remarkable. The information was not being shared. Having a better sharing system i will give you a for instance. Connecticut had an opioid sharing platform with 16 states, but none of the New England States participated. We had to break down that wall. We also reached out to the eastern premieres of canada. We understood that number one, they were incentivizing the prescription by medical policy of opioids that were not tamperresistant. Just the opposite of what you want to be doing. And, there were people in maine and New Hampshire and vermont, and i presume elsewhere, who were also coming across the borders with that tamperresistant, going there and coming back with tamperresistant. These are some of the things that you might want to be aware of. Lets do everything we can. The final thing, just because of our age, and i missed that both comments, i had to leave for a moment, so if you said this already heroin is purer than it has ever been. You do not have to shoot up. It is cheaper than it has ever been. Both of those points may have been made. This is the third point of that. People are dying on their first usage. We are having it happen on a regular basis. Young people think they are going to live forever, think they can tolerate anything. They experiment with heroin and if there is not someone to administer narcan, they are dead. Were seeing 18, 19, 20 21yearold. We see people at their 21st birthday parties die on first usage. We see them in graduation parties from college die from first usage. This is a big problem because of the expense and because young people think they will live forever. When we were growing up we all thought you would be a junkie in a week. It is very different now. It is cheap. But people are age are the fastestgrowing abusers, for many reasons. How much is prescribed is important. You have a tooth removed, there is no reason for a doctor to write a 30 day perception for an opioid. No reason for it. Come back. If you still have pain after you have a mole removed after three days, come back for a renewal. Stop writing longterm prescriptions. Gov. Beshear other questions or comments . Gov. Fallin i agree. That is on point. We do all the things that were just mentioned. We also have drop boxes. We all worry about national security, isis, terrorism, Cyber Security, but the enemy within the nation is the addiction issues of our population and how it is running lives. Whether it is children ending up in custody because mom and dad cannot take care of them anymore, a school child having trouble learning and they are falling behind, because parents are not available or someone may be in prison, maybe grandpa and grandma taking care of the kids. It could be those living in poverty, those who are not in the workforce. 62 of the people who can work do work. But many do not. Those who work and pay taxes have to help fund those programs and help those people. The workforce. This is a National Debate about how we can create a stronger america. But we are weak right now and we have threats outside and within, with our Substance Abuse and drug addiction problems. We need to have a National Debate, besides the points that were made, is working with the judicial systems, judges, and those who are involved in Law Enforcement, that if someone has a Substance Abuse issue and is not someone we are scared of that might harm us in our homes, a friend, relative, an acquaintance who has an addiction issue, do we put them in prison for 20 years . With hardened criminals so that they come out worse, or do we help them address the core issue, which may be an addiction issue, hopefully not heroin, but it is a reality. How do we do things better smart with crime, yet tough on crime . How can we get people treatment . In oklahoma, i have encouraged people to look at how to get this Substance Abuse treatment if they are just not criminals but people with a problem. I am trying to remember the new word substance challenged . Not Substance Abuse, what do you call that . Lt. Glynn Substance Abuser . I think sometimes we get caught on terms to much, we go back and forth. Some parts of the country do not want to say addict. Gov. Fallin substance disorder. But working with the criminal justice system, it costs money we know the outcomes for longterm. We want to keep those who are dangerous to the community locked up, absolutely. But how can we help family members, colleagues, as you were identifying addict versus a mother, daughter, colleague, friend, who has an addiction issue how can we change that dialogue in america to help people who have these issues . It is one of our biggest challenges. It is weakening us as a nation. We have bigger issues like terrorism and things we are really worried about. But we have a weakened society and we are weaker as a nation. Gov. Mcaulin mary, you talk about Public Awareness. How can we do a better job of that . This is the key issue, get people to understand the issues and get them involved. Mary thank you. I look to you for some of the answers. I have some personal thoughts, they may not be politically correct, but i will say them. And then i will speak to governor fallin and her questions. In this time of the legalization of marijuana, i think that kids are hearing some mixed messages. They hear that pot is ok, it is safe. But i think that the overall message right now on drugs altogether for the youth is warped and more people should say, this stuff is stupid. We are not hearing this message. It is just stupid to do it. The just say no campaign that the first lady reagan, many people said it was not successful, but we need something my back. Like that. It is stupid to do that. We are not hearing that. So even though we are looking at marijuana, in my opinion it is stupid. I will be one of the people to say it. Im not popular with some of my kids friends, but i say it everywhere i go. And we have arguments at the dinner table. It is important. I congratulate your state to be one of the less transitioning. But to governor fallin, there seems in the Recovery Community that they are enthusiastic about the comprehensive recovery addiction act. Portland im fine with that. It is gathering a lot of steam. Tremendous bipartisan support. Within that bill, there are guideline reforms. Congressman brenner is the cosponsor in the house, so guidelines are in there. We need some more support to get to the market level. The priorities of the country right now, it is hard to get senators to focus on this, but we are doing our best. With this bipartisan nature i think that we have a good chance at it. Again, the notion is people with Substance Abuse disorder should be treated, not incarcerated but that this is one of the fundamental points of the bill. I can send this to your office and see if you can weigh in, maybe want to cosponsor or jump in. Gov. Beshear dr. Houry . Dr. Houry we worked with kentucky. It is about changing norms and getting people aware that it can be your neighbor, not some scary picture that you are used to seeing. We have people telling stories of how they recovered from addiction. It is hopeful. You can see yout neighbor, your colleague in that and it is just getting that message out there more with those stories of recovery and those stories of loss. Children that they lost due to addiction. And then attaching that to how to get help. Gov. Beshear governor tomlin. Gov. Tomblin we have had some successes and we continue to strive just as much. But we have had successes in closing down these drug mills, changing the rules, i agree with governor malloy that one state cannot do it. Kentucky and West Virginia have worked together to share information so that you do not have people crossing borders getting prescriptions and bringing them back. One thing ive noticed, a decline in estrogen drug abuse Prescription Drug abuse it has moved to heroin however. We have passed a bill because of the increase of hepatitis c and hiv cases, we have started to implement Needle Exchange programs. Because i think a lot of people with that as promoting drug abuse, but i think once you get it, you are using drug needles state will pay to treat you for many years to come. One of the other things with that, five years ago we did not have the communitybased Treatment Centers that we needed around the state. We have been able to work with the legislature to now have a lot more communitybased services. Many of them for women and children. Those are now in place and most of them are and we continue to expand those services. People really didnt, if they wanted to get off of drugs, they really didnt have a local assistance, or the whereabouts to go to a place. So i think that those will continue to be helpful. And also in the next 30 days we will have a statewide hotline, if you need help and dont know where to go or who to talk to to allow people assistance or to get help, i think people get to the point where they dont know where to turn. It is up to us to be able to supply that. We need to give it to people who have a sincere wish to get clean and stay clean. I think that it is something all of us will need to continue for a long time. It is something that we cant eradicate and 35 years. We will continue to monitor it as the availability of different drugs comes about. About. Time for one more question. Governor hutchison . Gov. Hutchison what a great topic. I want to applaud my fellow governors. Thank you for sharing stories. Detective glynn, thank you for your leadership and furthermore. I wanted to make a couple observations. I understand the seriousness of this issue and the message that we have to treat them as people with addiction problems, but also crime problems. But i would encourage you to and i think that you do, but recognize the Important Role that Law Enforcement plays. Whenever anyone has an addiction problem, it is rare that they say, i have a problem, i need help. It is generally when they are confronted by Law Enforcement officers that they first confront their addiction. And in drug corps graduation, it it is usually that Law Enforcement that is thanked. It is so important. Law enforcement sometimes gets beat up on the head that they are the problem, rather than the solution. The other point dr. Houry made was at the role of the state medical boards. If there is any Lessons Learned across the state, because medical boards are independent and they are made up of physicians. They have a serious response ability when you have a physician prescription abuse problem and the disciplinary action that they take. If there are any good examples or models as to how these boards address this, i would be interested in that. And finally, im familiar with methamphetamines and the length of time needed for treatment but if you have somebody in drug treatment, what is the optimum amount of time for someone with opioid abuse . 30 days is not enough, 60 days is not enough, what is the recommendation . I know that i raised a couple of different issues, but maybe dr. Houry, you have a comment . Mary there is no set time for opioid recovery programs. My honest opinion is that it is a lifetime of recovery. That once they have a substance disorder, they battle it for the rest of their lives. That is why Early Intervention is key. It can be, depending on the motivation of the individual, it can be sooner rather than later. But you made a good point, everybody in the addiction world recognizes that for someone with Substance Abuse disorder, to seek help, they have to hit bottom. That means a lot of Different Things to a lot of people. That could mean crashing your car, getting fired, getting arrested, it could be a host of things. Intervention from Law Enforcement, god only knows. But then that person hopefully would recognize that there life is that their life is not getting better. It is important. I think you for the work you have done thank you for the work you have them. This is my last filibuster there is hope for addiction and people in recovery. There is a good book out there right now called fearless. It was about a man who is addicted to cocaine and uppers and he beat that addiction. And he became part of an elite fighting group. He was killed in action, but his story was extremely powerful. I encourage everybody to read this book and find inspiration. As the detective said, it is lives we are saving. Thank you. Lt. Glynn 30 days is great, but that is just one prong. Hopefully they are in recovery for a long period of time. But there are relapses. That is not a failure. As far as Drug Recovery goes they graduate many people and those people falter. The judge has no problem putting them back in the house of correction. They joke about it at graduation. How hard it was to go through and judge so and so put me back in jail, but that was a turning point for me. A quick example of the fact that they did belong to someone, a couple of years ago i received a package at the police station. It was nicely wrapped, it was christmas. I had a detective open it and they brought it back and it was from an individual that i had arrested a number of times. It was a christmas present. It was pajamas. They were very nice. It took that person to a point to see me as a human as i saw them as a human. I chuckled, there was a security tag on the leg of the pants. But the thought was there. [laughter] the thought was there. That was one of my biggest tipping points also, to think of someone as a person, but with multiple issues. They are still clean and sober after three years. It took a long time and that was a step that maybe they had to accomplish. That appreciation. It wasnt just appreciation for me, but for Law Enforcement in general, stating that we were out there helping, but also we are enforcing laws. I wanted to close with that. Dr. Houry that is hard to follow. I think that there is good and bad when it comes to state medical boards. We want them to work, but doctors also worry about if they are not prescribing enough, that patients complain and go to medical boards. We want to ensure that doctors are safe from that. I do not have a happy story to share. It is difficult when you are on that front line and someone is asking for a prescription and you have to say no. We need to empower doctors and give them protections through the state medical board, to say no when it is not appropriate and have that difficult conversation with the patient. It is easy to given and say, here you go. Then you do not have an unhappy patient. I have referred patients before to pain clinics, but that is tougher to do and i think that we need to have these conversations so that people are aware of the growing problem and how we can make a difference. Gov. Beshear we will close out the session. I want to thank everybody for participating. It is obvious that this is a fundamental problem in our society and it is not going away. Unless we stay focused on it from state level to federal level, it will just get worse. If no one in your family, or no one in your extended family, or no one of your friends has ever been affected by this consider yourself lucky, because it is everywhere now. I want to thank the nga for focusing on this, this is something we need to stay focused on and continue to learn from each other because there are good things going on out here in the different states and when we passed our legislation we pulled from a lot of places. We did not try to reinvent the wheel. We wanted to make sure that we were covering the waterfront. I cannot stress enough how it takes every stakeholder, everybody, to make this work. It has to be many involved in this. Lets give a round of applause to our panel. [applause] any closing comments . Very well done, very helpful. Thank you, that was fabulous. I want to thank you mr. Chairman. This is your last meeting of the summer. You made us proud to be governors. Gov. Beshear thank you. [applause] we will have more from the national Governors Association any moment. A look at tomorrows newsmakers with Harold Rogers. He is chair of the House Appropriations committee and talks about the budget process this year in congress. Do you sometimes wish you had earmarks back . Yes. You consider that a big factor . It is an aid in passing bills. More importantly i think is, the congress by the constitution controls the Purse Strings of the government, supposedly. That presumes you can pass Appropriations Bills in order to exercise that power of the purse. We have not been able to do that. The bureaucracies and in the executive branch have had free will. So congress has punted the ball down to the executive branch and debris accuracies bureaucracies decide what to spend. Thats not how it is supposed to be. That is my concept of what we should be doing. Part of that is with earmarks. Nobody knows better than me the needs in my part of the country because i spend my time there and lived there. My staff is there and we work on case work all the time. I know what needs to be done there. Better than any bureaucracy downtown, 600 miles from it. I think earmarks in very good moderation are sensible and a good thing to have. You can see that entire interview with representative Harold Rogers tomorrow at 10 00 a. M. And 6 00 p. M. Eastern on cspan. Another interview to watch is our oneonone with democratic president ial candidate Lincoln Chafee who recently talked to was about the 2016 race, his life story, and his decision to leave the republican party. Its part of our ongoing road to the white house coverage. You can watch at tomorrow at 6 35 p. M. And 9 35 p. M. Eastern on cspan. Considered underrated by many first lady historians, Caroline Harrison was an economist artist who took up china painting and carried that interest to the white house, establishing it china collection. She was interested in womens issues and helped raise funds for John Hopkins University on the condition that it admit women. She was the first president general of the daughters of the American Revolution until she died in the white house from tuberculosis. Caroline harrison, this sunday night at 8 00 p. M. Eastern on cspans original series, first ladies, influence and image examining the public and private lives of the women who fill the position of first lady and their influence on the presidency for Martha Washington to michelle obama. Sunday that 8 00 p. M. Eastern on American History tv on cspan3. More now from the national Governors Association beginning with health and Human Services secretary Sylvia Burwell talking about state health care issues. Then, thomas perez talks about state Economic Growth through job creation and other means. I want to welcome everyone to the closing session of this summer nga meeting 2015. We will spend some of this session examining Health Care Transformation and i am very pleased and grateful that health and Human Services secretary Sylvia Burwell is here with us today. She has been a truly generous with her time, attending our last two meetings and picking at our governors only lunches. She oversees more than 77,000 employees and her work touches the lives of all americans. Most recently, she served as director of the office of management and budget. She has also served as president of the walmart foundation, president of the Global Development program at the bill and melinda gates, and perhaps most importantly to governor tomlin, she is a native of hinton, West Virginia. My home state of colorado is an example of working with cms on Health Care Innovation on a variety of levels. For those of you who may not be aware, cms has approved the largest combined Data Warehouse and analytic system for helping Human Services in the country in colorado. This system hits all components of the cms triple aim of working to provide better care for individuals at Higher QualityBetter Health for our population as a whole, and reduce costs as a result of those improvements in Health Care Quality for all of our citizens. Without further a do, let me introduce Sylvia Burwell. [applause] ms. Burwell it is great to people to join you all today. I am especially happy to welcome you to the mountains take along with governor tomblin. Less than an hour away is my hometown. I want to invite all of you to visit kirks home of the hungry smile. It is both where my sister and i started as waitresses many years ago. I hope you will go by. If you dont want to go there the dairy queen is only a halfmile further. It is the most beautiful dairy queen in the nation. [laughter] i am not one to brag, but it is in a book. This is true. If you went and sat on the patio and saw the herons and the bald eagles, and you saw the new river, you would say it is. I want to invite everybody and tell everybody to tell them i sent you. I am from a town where Everybody Knows everybody so please do head down to hinton and check it out. Kirks was my first job and it is really where i learned about hard work. If you got stuck serving the hard serve ice cream after church, you just kept zipping. It didnt matter how these poor arms started to feel. You worked until you got it done. That is one of the lessons i learned in hinton and i also learned about community. That was what hinton was all about. You worked together to get things done. I know that those of the ideas we share as we head our conversation. It is something i find particularly valuable. It has been one year since i first met you all. I literally had not been secretary for a month when i came to visit you and we were hosted by the governor of tennessee. I had the opportunity to get to know a number of you, some of you are new around the table but i think i have gotten to spend some time with you. I can understand and see your passion and dedication for the people you serve here it you have all been great partners and great supporters on a wide range of issues that hhs has, whether that is ebola, Early Education preventative care, and i want to start by saying thank you to you all for your partnership in this year. You are all on the front line of governing and i know how you feel. You have to answer for your work every day and we depend on you because you are citizens because your citizens depend on you and you are crucial to our work. We appreciate that and thank you. I will deliver some remarks but then i want to hear questions and our conversation. I want to ask you for your leadership and one of the most important things i think that is happening in the nation right now is transforming the quality and value of health care for the folks we all serve, the American People. It is a historic time and each of us have the chance to help reshape this system, to make changes that will help Business Restart economies, and help the lives of the American People and its a chance i think for us to lead together. I have had the chance to discuss with a number of you shared health challenges. For too long, our systems have failed with the patient first. Americans have struggled to navigate an expensive and complex system. We pay for more care, but sometimes we have actually gotten less. In the last few years, we have actually started to see some turn in that. We have rigged reduce the number of hospital admissions to 8 . We have increased safety and hospitals with a 17 reduction in the rate of hospital acquired infections and other things that people have happen in hospitals. An this is a Foundation Wiki and build on. Like all of you, we want to build a better system. One thats mens our dollars more wisely and puts educated consumers at the beginning of their care to keep them healthy. We have been trying to take some steps to make that easy. This new model will create one payment with quality measures for an episode of care. The 90 days from the point at which you have your surgery to the point you are supposed to be fully recovered from a hip replacement. So rather than being incentivized by checkups, they will have a chance to focus on the quality and total cost of performing a hip replacement and the included recovery. Since medicare and medicaid covered nearly one in three of every americans, we will only be able to deliver truly significant and sustained change if we have support from hospitals, providers, insurers and we work with the state to make this happen. State efforts can go a long way in changing the status quo. We hope you will set your own goals and find better ways to deliver quality. And, to let us know how we can help. We have an established the Health Care Payment and learning network, where private and Public Sector leaders can come together and share ideas. Many of your state health care and Business Leaders are part of it. 4000 members and 6000 organizations. I want to thank all of you that have already participated. We hope you will all join this conversation, because it is a very important part and we want to make sure we move this as quickly as possible. We must Work Together to see around corners. Changes something that results in things that are known and unknown, but if we Work Together we can minimize negative impact. We have seen great leadership from many of you. We can look around this table, and we are working with most of you are not. Through medicaid and the state innovation model, many of you already have grant funding. We can continue to provide those resources and technical assistance. Another area where we see great collaboration, is efforts to combat the prescription opioid and hera one of use and our country. Last and heroin abuse in our country. We are working to tighten up the prescription and tightening up the usage to stop overdoses and we are expanding access to medicaidassisted treatment. I did not write just to inform you, i wrote because we need your help and your ideas. I have had the chance most recently to be in massachusetts with devon or baker and be in colorado with governor hickenlooper to mac out to map out a path that we can work through. Many of you are finding innovative ways to combine behavioral and primary care together, which is related to this issue. I am happy to announce we are going to create new ways for states to use waivers to address Substance Use disorder. It will help states provide an effective care coordination models to Better Connect those with Substance Abuse needs to treatment. We are also working to address existing demonstrations and we have released guidance. For the approval and three approval of longstanding medicaid and other demonstrations which will streamline the extension process and reduce the burden on state and federal government. We will award in 11 million in grants to help states provide medicaidassisted treatment for opioid treatment disorders. We will make treatment available for hundreds of Community Health centers to improve and expand treatment for four opioid treatment. So you have a sense that is large. It was not in my remarks. I am looking at the press person who will now take care of the fact that i Just Announced that. [laughter] [applause] sorry, been. As we learn what is effective it is important that we share these best disses with each other. That is why the Prescription Drug academy is so important. We are convening representatives to all 50 states and i have sent a letter to all of you asking for three to come together in september so we can continue to Work Together on that progress. Thank you for those of you to help with your leadership on that progress. I want to mention Something Else that is helping to change the system. The revolution a helping in Biomedical Research is a place where we can change the nature of the care we provide. We can begin to personalize medicine like never before. I have had the opportunity to meet with the scientist and patience. I met with a gentleman from south carolina, he came to the nih with Kidney Cancer in 1992. He had a rare, Hereditary Cancer with a mutation called the emmy t mutation gene. It causes tumors to continuously grow. He had to have one kidney removed, and on the other kidney, he has had 96 tumors removed. Things to Precision Medicine and our doctors at nih, they were able to find the genetic cause of that tumor and develop a treatment. At first it was management. Understanding how they were growing and helping them to shrink so they would not need to remove. But eventually, don received a target drug and his tumors shrank and are now at the a point where don lost a father to this, but don is now doing fine. He sent me a note that said, often the best you can do is give somebody help. Some of the most interesting events i do are with the scientists and the patients. They are the people doing the science everywhere. I encourage you as part of the overall vision of where science is going to meet with some of those folks. It is interesting, exciting, and you see the vision of where we are going to go. Before i close, i would not be doing my job if i did not raise the issue of expanding Health Care Coverage for many working citizens in your states. I think you know what im talking about. Laughter [laughter] this is about the financial and Economic Security of your citizens and state. In every state that gets expanded medicaid, more then 4000 americans can have access to Affordable Care. These are lives that could be changed and in some cases, even saved. In 2014 alone, we reduced hospital uncompensated care costs by an estimated 7. 4 billion in the country. 5 billion of that, 68 is estimated to come from the state that does that expansion. We know there are challenges, but i want to make sure you all know i am working with you to find solutions. We welcome this conversation and we want to help you design a system that fits you and your state. One of my favorite parts of this is building relationships with all of you. I have seen you are beautiful states, drink great lemonade, and i have been sent home with homemade cookies. My children got to eat doughnuts in a governors mansion, you know who you are, and it is official. You are their favorite. What i said one year ago, i still it i still believe. We wont agree on everything, but we have common interest and because of that we share Common Ground and a commitment to serve the American People. When we can Work Together, we can do great things. Thank you for having me back again. I look forward to your questions. [applause] two things i think were apparent there, one is that the West Virginia accent, the twang is back. Second i think also that your approach is a combination of private sector and Public Service you have done throughout your whole career which i think all of us appreciate. We have time for questions. He wants to ask the first question. Governor hutchinson . Governor hutchinson thank you for your presentation your desire to find middle ground with many governors and to look for more flexibility. I have enjoyed our discussions in that regard. I also appreciate the connection you have to the dairy queen and the confection you have to arkansas and the time you spent there. I might have missed it, but i wanted to give you the opportunity to comment, if you have not done so, you mentioned the 1115 waivers. I would like for you to comment also on the 1332 waivers. Because, there is an understanding, at least in my neck of the woods that the 1332 waivers were designed to provide Organization Type grants. A broader arena of grants or flexibility beyond simply the traditional medicaid. You and you comment on your approach to these waivers and what widens you can give the states . In terms of 1330 two versus 1115 1115 are focused on medicaid. 1330 two are waivers about the marketplace. The legislative history and those which promoted 1332 are the ones that one in singlepayer options for states. That is not necessarily what 1332 is about. It is about the ability to actually meet the objectives and goals. It is set out in the statutes pretty clearly in terms of budget neutrality, affordability, access, that is happening through a marketplace approach an exchange approach, where a citizen in your state receives a tax subsidy if they are eligible to go into the marketplace and have helped through tax sharing and subsidy. If a state cant figure out a way to meet those conditions and it is pretty clear in the statute and terms of the affordability, it is about the quality. It is about the access it is about the budget neutrality. We want to give the states that opportunity to come in. We have recently put out additional ways and which states can have these conversations with us. I think you all know they do not kick in until 2017, but it is pretty important, 1332 application to medicaid bonds, that waiver is about the other piece, the subsidies. That funding. 1115, and we want to work to be flexible as i have indicated. In terms of how you spend your medicaid daughters dollars and how you advance that program. So, they are different. Thank you. Governor markell and governor mccullough. Virginia is one of those states where we have not closed the gap. We forfeit about one billion a year. We are working to find a bipartisan way to get it done and i want to thank you and your office. You have been spectacular. To help us come up with creative ideas. We were successful on the state mile for innovation. This is driving innovation in virginia. I am wondering, what is the possibility for continued funding for these types of grants to help us to the reforms at the state level . We do not have a plan for round three. We have already done round two. One of the conversations that is happening right now, an important conversation then not much attention is paid to much now, you are all focused on a transportation conversation, which is another important one. But another important one that is important to all states as well as the nation is the actual budget conversation. I think you all know, that right now current law is at a sequestered level. And for those at the hhs, it is some of the lowest funding and over a decade. Some of these questions will be answered as we move forward as part of these conversations about where we are in and where were going to be. You know, i am hopeful there will be at another in the ryan murray approach and we can move forward, and that is going to happen. That is not a specific answer to your question, it certainly as we think through things, it is related. Madam secretary, delaware also received one of the grants that allowed us to accelerate significantly our work to try to move away from the fee for service model. In, my question, and it really means improving access improving quality and the cost curve. We are encouraged by how all of these stakeholders are really at the table and working together. My question is really around the cost issue nationally. And certainly, some of the things i have been reading in terms of National Health care cost and rates. It seems like there are a lot of increases around the country and despite efforts in many states to try to move away from the feeforservice model. I wonder few could comment on that. With regards to the issue of overall costs, whether it is caused in the private market or cost and medicare, what we have seen as some of the lowest cost. I was reading an article by kaiser. Weve seen some of the lowest growth on record. This weeks article said 50 years in terms of per capita cost growth. Medicare growth, having just on the Medicare Trustees meeting over the last five years, to give you a sense, in the last five years, medicare cost growth has been at 1. 2 . It was, the for the four years before, at three point 6 . There is a second part of your question we are all hearing a lot about. That is the issue of rates in the individual market. What is interesting, one of the things about the Affordable Care act was the question of transparency, so thats things have to be shown in the light of day. Because i think we actually believe the light of day is a hand and important market function, because that is how people get information. What happens is now, in each of your states, any insurer is putting forth rates above 10 it has to be made public. It has to be listed during the review. Most of your route most of your states review those rates. That is what is happening right now. The insurers have said they believe the people who will be in the marketplace next year and this is just the original market, we know the rates usually come down. We know that a number of states, i can actually look around, some of you your rates are out. Governor, you are in a state where we are seeing downward pressure. I want to say one other thing if something obviously, we spend a lot of time on it. The question of the cost, the rates, the pressure. It is something we want to watch. We want to be on top of. One thing i would mention, as i look at the numbers, in the out years, in terms of the cost and medicare, because it will probably be reflective of what else happens in that market in my cover stations with ceos and others there are some pressures in the drug space in terms of upward pressure. We can have some conversations about that. The one thing i would say, think there a number of things, we think light of day is important for that. In terms of knowing what drugs are costing and how much. That is something the public should know and understand. And we are fast for these authorities in our budget, for Medicare Part d. Can we have the authority to negotiate . As you mentioned governor, i spent time at walmart. It is a place which negotiates with its suppliers and uses the power of the market to actually put downward pressure on price. In so, it is something were watching. We want to keep and i am. We always keep an i on. Right now, we are watching, but i think the conversation is not reflect if of where the market will and. We want to be cautious, as always. That is a place we need to focus. Governor mead. Governor mead madam secretary thank you for being here, we appreciate the year of your service. You have had great outreach to the states and your team work with wyoming as we were trying to expand medicaid, which was a colossal failure, by the way. They blamed the governor, so that is ok. It was not on your part. It anyway cut them but anyway, madam secretary, as you look at health care in the states and the country, i think one of the challenges we face in wyoming is we are a very world state and our challenges are somewhat different than the larger states. Just on economies of scale. Before the aca we had 12 or 13 Health Insurance companies in the state will stop we have two now. Ecosome of the lists were too big. The same is true on some of these systems necessary for payment, for example. We look forward to partnership with some other states. So, a general question, i think that World Health Care and world states, within our native american populations there are some unique challenges and we are working to find some of those answers, but i would just encourage you and your team to continue to recognize that there is some differences between large metropolitan areas and health care and world areas just in terms of distances and how far you have to drive when your son has a broken arm and those challenges. It is not unique, it is not new. I mean, this has always been a challenge. But certainly for smallerpopulated states, we continued to be very concerned about our different challenges. I agree and recognize there is a different. Being from West Virginia and a state where we have a large rural population, it is something i understand and recognize. We do not have the geographic expansiveness to look at states like your own, but some of the problems with regard to concentration and that sort of thing, i think, you know, when i sit in my seat and we are doing rolemaking, the one thing you will be pleased to know is now the center for medicare and medicaid know they cannot wring a single role in for my review without telling me the impact on Rural America, because it is hard to figure out. The announcement that i talked about, the hip and knee bundling announcement, that is in 75 markets. But for a market to be chosen because it is mandatory, the market had to be of a certain size because you had to have enough of a population where you could spread what was doing. So, we had those pacific conversations. The question in Rural America how do we work to make sure that in places where there is not as much competition, you know, that is one of the things how we create working markets is a challenge but it is one we want to work with you all on. We want to think through how we can do that. Hopefully, so you know it is one of the things they now have is a list of thing that they actually have to talk about when they come in, because i am going to ask it so you may as well be prepared in terms of what is the impact on world markets, because the markets are different. Numeral rural markets. And you all know that, even within your states, there is a difference in terms of what the markets look like. Governor herbert thank you madam secretary, we are honored to have you here. Many of us are still having ongoing discussions with you and your department. I want to express to you personally and to your staff the professionalism that we have been received with. You have been very cordial and willing to listen to our issues and we thank you for that. You said something i was taken with, and that was that we have more in common than we have differences. I agree with that. I think what we have in common is a very similar goal as republicans and democrats and states and washington, d. C. To serve people as best we can. To provide affordable, highquality health care to all americans. Where we sometimes have a difference is how you do that. The goal is the same, but the process and the pathway we follow is sometimes a little bit different. And that is part of the debate. You talked about the need and the opportunity for us to have waivers and get more flexibilities. Sometimes i think, it is like working. You cannot have it your way. You have to do it my way. And, you know, how do you determine, when it comes to the health care issues, when you give waivers and give flexibility, how do you determine how much leeway you will give to the states . How much will you let us try it our own way as opposed to having to do it, i dont want to say your way, but under the Affordable Care act where there is flexibility, how do you determine where that line is going to be drawn to give us the flexibility we would like to have a states . Usually, whether it is in this space or any of the other spaces that one is working, in terms of the decisions we make across a wide range of issues well beyond 1115 waivers, one turns generally to the intent of the statute into the intent of the policy. This is about, you know what the core issues are. With regards to the specific issue and 1115, as we think about what guides where those bright lines are it is often about affordability and and access. That was what the additional funding was about. It was about creating a better match, more enhanced money for state with in return, providing broader access that is affordable. That kind of gives you usually when we think about these things, what we are trying to do is go to what is the core objective and generally speaking, as we have the backandforth, try to find the places where we can be the most flexible about those things, and then where it hits up against some of the Core Principles, that is where we come to our places. I think it, similarly for you all. I find that in all of my conversations with you, in terms of you all, there are Core Principles you have trouble moving beyond, even if i would like to do it a different way. But we try to do is find that space. Because it is a negotiation. Thats what these each are. When i came in, our colleagues, you know some of my colleagues it would have been much easier with medicaid if i just put lines. And there are some places, where you know there are some lines i put. I made it, this is it. But i do not think that is actually what gets to our ability to listen and