Electricity from great batteries and methanol from natural gas to get the consumption of oil way down. Thanks, thanks for that question. The short answer is that there are inventors and companies and argan talk about this. Im sure, who are trying all of these. And one of the im a believer in natural car natural gas car future. And its for this reason, that so, you know, in economics, you know, does supply create demand does demand create supply . It goes both ways. One of the most interesting formulations is supply creating demand. And it goes back to the way i like to picture it, is the cocaine model. So did americans become hooked on crack cocaine because we started out being hooked on crack cocaine and then the cartel responded to that . Or did the cartel start pumping cocaine into the United States and then the market developed from that . So just transferring that over to natural gas, here we are in a world were utterly awash in natural gas. I checked yesterday, natural gas is 2. 86 per 1,000 cubic feet right now. Its incredible. And the horizon for it, for this supply, you know, is from here to eternity, and so there are big thinkers and they include ed morse at citigroup who ascribes to the cocaine version of natural gas. And thats that this surplus pushes itself into the vehicle market. That over the next pick your number of years, you do end up, because its so cheap, that natural gas vehicles with lng, cng, ends up pushing itself into the market. I want to broaden out your question a little bit. Its not just natural gas, its super capacitors, fuel cells. The first time when i rode the bus at argan, they were telling the chinese minister of science and technology was asking him what do you think about twinning batteries with fuel cells in order to get there. Its another good question, gy jim, thanks for that. I am very high at hybridization. I see the chevy volt to be a platform technology, the gasoline engine is just a generator. Thats all it s. If you could move to natural gas it would make sense. We at the lab are doing research on this. To me we would have been in the lab, we had all kinds of hallway conversations. We would have bet years ago pure electrics were way off. The odd thing is, i learned this enough in my life i should stop saying its new. You cant predict the consumer. The analysis i was telling you where the Adoption Rate of the hybrid vehicles are double that of the prits. In the last six to eight months, electric vehicles have out sold the plug ins. That makes zero sense to me. Why you would buy a car that has 80 miles per charge. And takes many hours to refill it with energy. Or to buy a tesla which is an amazing vehicle but costs hundred grand. I live 18. 5 miles from work. I can rely on expensive electricity in illinois. When i need gasoline to drive my son to a tournament in southern illinoisula i can do it. Can i just give battery with 300 miles per charge. What the consumer is used to is infinite range. The reason that every car goes 300 miles, they design the size of the tank to go 300 miles is fizz logical fizzologically thats as long as we can drive. We dont want the breaks to be longer than five to ten minutes. Theres no system in place regardless of how many miles you can put in juice in your battery to recharge it. So in short, jim, i agree with the what youre implying in your question, the hybrids are the way to go. It will have the same security implications in terms of the amount of energy that we have in our soil and elsewhere inside the United States. As a technologiest i think thats the obviously way to go. When you look at the huh doptad the consumer is doing something different. The early adopters will drive the equation will go down and well revert to hybrids or something. Thank you so much for the discussion. Im from china daily. Speaking of asia, speaking of china, i want to ask what china and the u. S. Could do to cooperate in terms of scientific research, manufacturing and also promotion of the new technology of energy resources. And whats the role of ecp in this cooperation. And, also, how they affect the economy, politics and the bilateral relationship between china and the u. S. Thank you. Thats a big question. So i will take a stab at this, but then im handing it straight over to you. All right. Only because youre right inside the game. And this is that the cooperation in my own view will happen after the innovation. After you know, the competition is too stiff, is the stakes of winning are too high for any of the countries to cooperate with each other. Youre not going to have, for example japan handing over its innovations to china or south korea or south korea doing so with china. Or the United States doing so with china either. Look at what happened with the lithium iron phosphate. This is the inventor of every body here who has a smartphone in their hands or in their pockets, he invented the nervous system of those batteries. In those smartphones. He invented another chemistry. And this went on to be reinvented by a bunch of other people, including a Company Called a 123 that built its batteries, factories to make those batteries in china. Resulting in 30 or 40 other companies, very, very quickly in china. Suddenly having exactly the same chemistry. Creating competition for a 123. For these reasons, i just i cannot imagine, you know, there being very, very close cooperation. At that competitive stage, where there can be collaboration or cooperation is in the rollout of them. Because both countries have very, very high stakes. China, for example, has a premier policy. Chinas right on the vanguard of cleaning up its air. And that this is the stage at which you can have the United States and china cooperating. Thanks for the question. Thats a big question youre asking. A lot of people are trying to answer that question right now. In the government as well as else where in the world of business. I guess id start by saying we all have to recognize, including our friends on capitol hill that we live in a world economy. Increasingly are living in a more and more transparent world economy. Even with the competition that steve is talking about. Were all well aware of. Ill give you a couple of examples of that. In the battery world, lithium phosphate is in the a 123 batteries. They came out of m. I. T. They had a problem that resulted in a 50 million recall. It did go public, i dont remember the year, Something Like five years ago or so. That one quality problem because it had one product bankrupted them them. They went out on the market and were bought. They were split apart. The defense part of their United States dod contract work went through navitas. The rest of the company went through a chinese owned company. That bankruptcy happened three years ago. The plant is now operating at full capacity in michigan sending every one of its cells, most every one of its cells to china. Look at it in the reverse. I think i finally converted over from android telephone to i was a very stalwart person, not wanting to go to apple products. If youre watching out there. My kids all use apple. I use apple products. Guess where theyre made, theyre made in china. We all love to revere apple as a premier example of how American Companies operates. Thats built on the backs of folks, manufacturing much of the intelligent that go s into the apple firm. Almost all of it in china. Are either one of those a bad thing . Im not a politician, im a scientist. Th there is room to collaborate in the research with other scientists from around the world. Its a tradition thats been going on for decades, if not centuries. Steve is right. The difficult part comes in maybe the exciting part comes in the collaboration, can you collaborate beyond the scientific research. I think you can, given the two examples i gave you. A 123 making battery cells in the u. S. To ship to china. And apple making products in china to ship to the u. S. I think weve run out of time. Thanks a lot for coming. [ applause ] thank you, steve and jeff, such a wonderful presentation. And thanks to everybody here for all of your excellent questions. I want to tell you that at least we have planned our second of our Technology Series on april 24th. Peter dean one of our senior fellows is here today will be part of that. We will be talking about the future of renewables from the viewpoint of the private sector. And where they see things going over the next months and years. I hope youll be able to attend that. Well be sending out notices of that in the next week or so. Again, thank you very much for coming. Thank you, steve and jeff. [ applause ] this weekend on the c span networks. Politics books and American History. Live from the iowa state fair. Candidates speak. Well hear from rick santorum. And lincoln chafy and Bernie Sanders. And more live coverage from the iowa state fair with ben carson and pataki. Claire mccaskill on her life and political career. Sunday morning at 10 30. Dinesh dsouza talks about his book america and his recent situation. On American History on c span 3. Were learn about the iowa state fairs history as we look back at the 2008 president ial race. Saturday, at 6 00 on the civil war, historian and author on the 1864 battle of mobile bay, the resulting Union Victory and the closing of one of the confederacy last ports. Legal and healthcare analysts look at the emerging industry of Online Medical care, also known as telemedicine. They talk about regulatory barriers, including licensing requirements, the roll of state boards and regulation. Coverage and reimbursement of services. A case involving the First Amendment and free speech by an attorney whos appealing to the u. S. Supreme court on behalf of his client, a veterinarian who was fined by a texas state board for providing advice through his website. My name is simon lester. Thank you all for coming out today. Thanks to those of you watching on the the internet and cspan 2. We have what i think will be an interesting and informative policy forum for you today on removing online barriers to medical care. Sometimes referred to as tell medicine or telehealth. Ive written about a narrow aspect of the issue, about how International Trade agreements address it. What happened was this. I was following the canada eu trade negotiations and i saw it in one of the legal texts they released that germany had excluded it from their commitments. They were saying were not going to liberalize. This annoyed me, so i wrote a paper saying actually, in trade negotiation, governments should try to liberalize cross border trade in medical services, but i realized if i were to just hold a forum on that aspect of it, it would be hard to fill my office, so i decided to broaden it a little bit and invite experts. I think well all benefit from their knowledge of the issue. This is a new topic for many people, so i think its best to start with the basics and get into some of the nuances as we go along. Here is the issue in its most basic form. For most people, medical care is something that takes place in a Doctors Office or hospital. You go to the Doctors Office, you wait a bit, they have these 1970s paper form, you wait more and they take you to another room and you wait again. Its pretty annoying, but what if instead of that you could just take out your smartphone and place a skype call to a doctor r go do some other things, get some lunch, go to a policy forum. And then when the doctor is available you have your conversation. It sounds convenient. Its actually being done, although i havent done it myself. The problem is in the highly regulated area of medical care, there are lots of hurdles that get in the way and a number of start up companies that are trying to break them down. But its not easy and its been a struggle. So, our first panelist is going to give us an overview of that emerging industry. The regulatory barriers that they face and efforts, ongoing efforts to address these barriers. Renee is a senior counsel at the law firm of epstein, becker and green focusing on health care policy. I came across her name when i was reading an article about these issues where he was quoted i feel like thats a good sign youre doing something right when the economist is is quoting you. Then to jeff rose. Jeff is bringing a fascinating case on behalf of a texas vet who was fined by his states medical board for offering Veterinary Advice online. Among other things this case involves important issues of free speech and although it involved a vet,itous has large implications on human beings. Jeff is going to give us a background of this case, tell us about status and its prospects. Then finally, we have josh, whos an actual doctor. Nice to have one of those on a panel talking about health issues. Hes also a policy wonk and a former high ranking Government Official dealing with health care matters. A dean and professor at the Johns Hopkins school of Public Health. Before that, he was at the fda and secretary of health for maryland. Josh, i suspect although i dont know what hell say, maybe the voice of caution saying hold on there, you free market loving libertarians, we cant just throw out all the regulations here. We mo need some in place. Each is going to speak for about 12 to 15 minutes, then well open it up to the audience for questions. If anyone has any cell phones, please turn them off. With that, let me turn it over to renee, who will get us started. Thank you very much. By way of disclosure, even though yes. Even though simon did introduce me, i represent a lot of telemedicine stakeholders, hospitals, health systems, health plans, some of the leading telemedicine companies. So some of my comments may be skewed in that direction. So, ive got a quick powerpoint were going to go through here. One of the things that i always start with is definitional. Telemedicine, telehealth. Theyre used interchangeably. As you can see, some of the major stakeholders cant even agree on what it means. Medicare has a very restrictive definition of they use the word telehemth health involves two way communication. It has to be audiovisual. So, ive put this up there just to show you that we cant even agree on a definition of what were talking about. Cant even agree on the terms. I see somebody here from the American Telemedicine Association. They use the term telemedicine. Others use telehealth. For me, what im talking about these issues, i really look at it very broadly. To me, its just a delivery of Health Related care, services, education and information by a telecommunications technology. Thats it. Very simple for me. Some of the usages of telemedicine, well get into some of this later, these are really the sort of three modalities. Some folks will tell you, will say the monitoring is separate on the part and i think gary and i have talked about this before. They consider remote patient monitoring separate, but just wanted to give you a flavor where theres a complexity here we need to Pay Attention to. Weve talked about real time. Where digital images and audio files are stored. Went to a provider who can look at them at some later point. Theres really no interactive communication between patient and doctor. Remote patient monitoring is what it sounds like. You monitor patients across distances and providers get information and can intercede during the process. What is driving issue . The discussion of telehealth . 17 years and this is i think for the last year, the first time where they have arrived. Whats driving some of this . Part of it is the aging population. Supposed to reach almost 370 Million People by 2030, but i think even more important than that is a percentage of those folks that are going to be 65 and over. Almost a fifth of the population. Obviously, the older your population, the older you are, the more Health Related issues youre going to have. Do we have the capacity to take care of the aging population s in addition to all the other things we need to do in the system . This is all coupled with the fact that a lot of folks are predicting a shortage of physicians. You see here almost 65,000 by next year. Going to double by 2025. So, youve got an increasing population, increasing share of aged population, plus, youve got the shortfall of physicians. You also have a Health Care System thats really in a transition from a fee for Service Environment where payers pay for services. So the one i will call income for outcome, where your payment, your reimbursement is really based on health care outcomes, quality, metrics, were in that transitional phases right now with the all the attendant problems everybody has read about. Also, technology. The sophistication of a lot of the Health Technologies that exist today is is incredible. Incredible. And the question is can our Health Care System absorb, pay for and manage the risk of the all this new technology. Thats part of the reason were here. Now, in terms of the Telehealth Market overview, these numbers are all over the map. But what i can tell you is theyre very bullish on this market. Bcc Research Predicts that the Global Market is going to reach 28 billion by 2017. Global health data does one better and says its going to be about 33 billion. Bergen estimates were going to be about 22 billion by 2020. And ihs predicts were going to be in the neighborhood of about 500 million by next year. Powers watson, one of the leading employer, Employee Benefits firms says the use of telehealth could result in 6 billion a year in Health Savings across the board for u. S. Companies. Just to give you a flavor of whats happening. Well talk about the landscape thats changing. Weve talked about the transition from a fee for Service Environment to one which were really paying attention to outcome. What are the legal issues we face. The first one we talk about is licensure. Ill talk about it for about five minutes. Because i think its an important issue in that i think there are some readymade solutions that some folks are attempting. The other thing, too, about license yur is we look at it from a physician perspective, but there are other providers that we have to consider. Scope of practice. Which ill talk about briefly. And how the relationships are established. And why those requirements may be a barrier and how some states are taking care of that. Coverage and reimbursement. It runs the gamut from very restrictive payment approaches by medicare to a mixed bag in medicaid. To a better overall picture for private payers. We probably wont touch on the rest of this given my limited time, so lets just talk about licensure. The piece you need to understand is is it follows the patient. There are medical practice acts all over the United States to govern what constitutes the practice of medicine, but somebodys practicing medicine, they need to be licensed in the state. What state do they need to be licensed in if youve got a physician one location and a patient whos out of state . In the United States, its where the patient is located. You can see how this impacts telemedicine if you have a dually licensed physician in pennsylvania, for example, who is providing care to somebody in north dakota. They need to be licensed in north dakota, unless they meet a number of exceptions and were going to talk about some of these solutions that have been developed. This has been a long standing barrier. And one of the reasons i think is if you think about health care in the United States although there are some local differences, i think for the most part a lot of the core requirements are the same across the board. The doctors practice the same in california, practice in urban areas, really a difference in practicing medicine in miami, new york, chicago. Thats the question that needs to be addressed. There are some exceptions to obtaining a full regular license that talk about some of these here, a special telemedicine license. Theres a consultation exemp as well, which we dont need to get into. Those exceptions usually dont revolve the overall issue of obtaining license in other states. The federation of state medical board, which represents 70 state and medical boards across the country has come up with a compact that only applies to physicians. Its a system by which license pormts portability is made a little easier. Depending on whether or not a state is a part of the compact. So for allstates that are part of the compact, being licensed with one compact states makes it easier to get a license in another compact state so you can practice. You still have to apply, its not like a nurse license compact where youre deemed license and if some other issues with the compact, so far i think six states have signed on officially. The federation of state medical boards, they need seven to make this work, so were almost there. I think another 15 have bills in various stages of the legislative process, so you could see ten, 11 states be members by the end of this year. So, this is one stakeholders attempt to address the license issue. The other big issue i see, before we go on, i should talk about nonphysician licensure. Compacts are being developed for nurse practitioner, physician assistants, but nurses have their compact, which i think 24 states are a member of. Interestingly enough for the nurse compact, the big states are not members. Texas, california, florida are not members, so it limits the utility of the compact. The other issue i really quickly touch on is scope of practice. How physician patient relationship is established. The one thing here i want to emphasize is that in order for physician patient relationship to be established among other things, most states require some kind of examination of the patient. What constitutes an examination varies from state to state. In a lot of states, an in person examination of that patient is required. As you can imagine in the telemedicine encounter, that may be difficult. Some states have seen fit to pass statutes which allowed that examination to occur by telemedicine, meaning if you can get the same information you can get in the telemedicine encounter that you can get in perscription, those states say thats fine. The problem is we have not yet developed enough diagnostic technology to make those examinations to facilitate those yet. And so what we see a lot of or what i see a lot of is Telemedicine Services without even doing an examination. There is a video connection with that particular and a lot of folks concluding thats not enough. That doesnt constitute an examination by telemedicine. Now, the federation of state medical boards again came up with a model policy for the appropriate use of technologies that sought to loosen some of the restrictions. Involved in the practice of telemedicine and one of the things they talked about was the examination issue. To decide whether or not they had information to diagnose and treat. Unfortunately, the model policy sort of exists in some state medical boards have seen fit to adopt some or all of this, but theres really not a lot of Energy Behind passage of the fsn b model policy. A lot of other stakeholders have developed cz zt sq protocols. I know the American Telemedicine Association has an Accreditation Program for direct to consumer care. The American Medical Association is developing their own set of protocols, so theres a lot of activity thats occurring in the space right now. The other thing i want to talk about before i leave is reimbursement. I should tell you under the medicare telehealth benefit, just a little under 14 million was paid out last year. Out of 615 billion in total reimbursements last year. That represents. 0023 of the total. It doesnt really may for telehealth. Theres a number of reasons for this. The approach being taken by medicare is this is really for the people in the most rural areas in the United States. Thats the first restriction. There are only certain kinds of providers that can provide fs is ises and be paid under this benefit. The patient cannot be in the home and receive services and have professionals be paid under this. The last thing, only certain codes are paid for. There seems to be a trend in psychiatric services, having those reimbursed as opposed to others. Theres a bias that telemedicine is not suitable for nonurgent primary care type purposes. Medicaid is a little different. Most medicate programs, as you know medicaid has more flexibility to decide what services they will and will not cover. Medicaid, most Medicaid Programs cover telehealth and telemedicine in some form. But the coverage requirements vary state by state. Some of them follow the medicare very restrictive rules. Some are more liberal on the issue. If you cover remote patient monitoring, if you cover scorn forward, the, theres no uniformity. Really, theres no logic to what states can and will cover. I think this could change. Especially as Medicaid Programs come under pressure. The private payer world is probably in a better spot. A number of states and gary, you can correct me if im wrong, have statutes in place that require private payers to pay for Telemedicine Services if they are still covered. So to cover telehealth and telemedicine. The definition varies state by state. Ultimately, they dont mandate the same reimbursement levels. I should caution you on that, but the private payer approach i think is a little bit better than you have with the public payers. The other thing, too, even in states that dont have the statutes in place, what we find is a lot of private payers see a benefit in providing these services. Whether theyre required or not and ive listed here some plans that none of them are clients. Some plans that are known as being progressive about telehealth and Telemedicine Services. I will finish by saying the one other aspect to really, really Pay Attention to in the coming years is employers. A lot of employers are very, theyre encouraged by what they see and the value they see in telehealth and medicine. Theres the impending cadillac tax coming in 2018. We can talk about that at some point, but employers need to be incentivized to look at a way to control the cost of their employees. Thank you. Thats a great introduction. Turn it over to jeff whos going to take us through a case study. What happens when you provide services online. Sure. Thanks. And thanks, renee. So, one of the reasons why telemedicine presents such a challenge is because medicine is is a vivid illustration of a peculiar reality in america, which is everything is forbidpen unless it is expressly permitted. This amazing fresh innovation comes along and all the medical boards say, well, you cant do that. We need to write 10,000 regulations, we have to subdue it with a regulatory process because after all, this is america. If we dont have a statute, you better not be doing it. And in part, thats because we have a 19th century or early 20th century regulatory model. We have 50 different states, each with their own boards and that doesnt even take into account the fact americans can now talk to people all over the world. There are billions of people who would benefit from the expertise of well educated americans and its completely unclear whether or not they can get it. Now, the thing about telemedicine is that at bottom, its just two people talking to each other. Thats it. People are talking to each other. One person wants some knowledge that another person has and they want to share it. Now, at least by reputation, we live in a free country, so, what does the First Amendment have to say about that . And this turns out to be a really interesting and one of the most important unsettled questions in constitutional law. Imagine and this is a true story, imagine a group of scottish missionaries go to rural nigeria and a married couple finds a stray cat and they think, were going to adopt a stray cat. But there are no veterinarians, no pet food, but one thing they have a cell phone tower and so, these missionaries can get on the internet. Now, go all the way around the planet and you find ron hines, a retired, physically disabled texz licensed veterinary. He spent his career working with exotic animals at a Research Facility here in maryland. He worked at sea world, he was in private practice. Hes just an amazing veterinarian, who after he retired because his disabilities made it impossible for him to work, he still wanted to help animals, so one day, he and the missionaries in rural nigeria, start writing emails to each oh about what to do with the cat. How should we feed the cat, make sure it stays healthy . It was a stray cat, what should we be looking out for . So, ron and the missionaries are exchanging emails and ron starts doing this with some other people, too. Mostly for free. Although occasionally, he would charge a flat fee of a couple of bucks. Just to cover the cost of his website. He never made any money doing it. So, what has just transpired . A disabled 70yearold man in texas writes an email to a scottish missionary about a cat in nigeria. Thats a crime. And ron hines had his veterinary license suspended, he was fined, forced today retake a portion of the veterinary licensing exam and shun down his website and stop doing it. And why is that . Because under texas law, you have to physically examine the animal before you can offer any opinion about it. So, this house bound, physically disabled veterinarian was supposed to get on a plane and fly to nigeria before he could offer an opinion of any kind about this cat and never mind there are no veterinarians and the cat would be without care without ron. Ron wasnt prescribing medication, sending drugs, just offering an opinion. Thats it. Two people talking to each other. So, whats the First Amendment have to say about that . Because its supposed to protect the right of americans and of which ron hines is an american and indeed, anybody subject to american jurisdiction generally speaking to have useful conversations about the world. Well, we brought a lawsuit and the trial court, federal trial court you know, what, youre right. The state of texas tried to get it dismissed on the grounds that when two people talk to each other, if the conversation is subject to occupation licensing, the conversation is by definition physical conduct. If he writes an email that says you should try to feed your cat some shredded pork or Something Like that. The law treats that as though ron is taking a scalpel and cutting a hole in the animal. He said it is conduct, even if its just words, so the First Amendment doesnt apply. Its not that it applies and you happen to lose under whatever balancing test there is, its that it doesnt apply at all. So, the federal trial court said the First Amendment applies. The state of texas asked for a special kind of appeal an we went up to the federal court of appeals in march, the federal court of appeals reversed. And they said you know what . We disagree with the trial court. We are going to call that conduct. That you are speaking and you are giving someone individualized personal advice, were going to call this conduct. So, whats going on . Whats going on is the collision between two venable constitutional doctrines. One is that state governments have Broad Authority to license occupations. That is well established in the law. We challenge it all the time. It leads to all kinds of irrational borders to entry. One of the reasons why medicine and other professions are expensive and hard to get into, lobbyists create all kinds of barriers. Set that aside. The Supreme Court have said states have broad latitude. They have also said the protections of the First Amendment are broad. And so what happens when those two things intersect . Well, the Supreme Court had an interesting case. About advice to foreign terrorists. Some american doctors and physicians were providing individualized advice to foreign terrorist groups about how to resolve their grievances nonviolently. One was the Kurdish Liberation Movement and the other was the tamla movement in sri lanka. These groups were concerned about being prosecuted for providing individualized advice, which they considered support to terrorist groups so, the question that went to the Supreme Court was is individualized device consists of nothing but speech, just talking to them about the law. Is that something protected by First Amendment and the Supreme Court said yes. The First Amendment applies. The federal government has a huge interest in suppressing advice to terrorists because its it frees up resource, but the First Amendment applies. So, we tried to take that precedent. And we said to the federal court in the fifth circuit. If the First Amendment at least applies to individualized Technical Advice to murderts foreign terrorists, surely it has to apply to a veterinarian in texas who say talking about a cat. No. Heres another case. Which involved what are called animal crush videos and so, there are people out there, perhaps probably not anybody in this room, but there are people who like to exchange videos about animals getting tortured. It provides them with sexual titillation. The question they addressed was whether it applies to a statute that restricts communication in the form of animal crush videos. The Supreme Court said this is america. This might be repugnant speech, but the First Amendment applies. So what does this mean for ron hines, the veterinarian in texas . What it means is, if he decided he wanted to talk to kurdish terrorists about how to, like, lets say they have a herd of cattle or Something Like that and theyre using that herd of cattle to support their fighters or something, he could talk to them about that, and the First Amendment would apply to that conversation if he were to be prosecuted by the federal government for providing Material Support to terrorists. Now, if ron hines also wanted to exchange animal crush videos with scottish missionaries in rural nigeria, the First Amendment would apply to animal crush videos. According to the fifth circuit, the First Amendment doesnt apply if ron hines is actually just trying to help an animal. So if he wants to help terrorists, or he wants to trade fetish videos, no problem. But if he just actually wants to sit down and talk to somebody to help their animal, no, no First Amendment protection. So this is actually a big issue. The federal courts of appeal disagree about the extent to which the First Amendment applies. So we have a case from the early 2000s in california, that involved medical marijuana. And this was before california at that point i think had said that medical marijuana would be okay, physicians could prescribe it. So its still legal under federal law. So doctors have a controlled substance license from the Drug Enforcement agency to be able to prescribe drugs. And it turned out there are a group of doctors who wanted to be able to say to their patients, look, im not going to prescribe marijuana for you. I cant do that. But im going to tell you that actually in your case, i think there is a valid medical reason for using marijuana. So a conversation between a doctor and patient. The u. S. Court of appeals for the ninth circuit said the First Amendment protects that conversation and the Drug Enforcement agency cant pull your controlled substances license just because youre a doctor having a conversation with a patient about medical marijuana. As long as youre not illegally prescribing it. Because the First Amendment applies even to doctorpatient communications. That should have been a good case for us. We cited it extensively in the fifth circuit. On the other end of the country, in the 11th circuit, there is a case going on right now sometimes called the glocks versus docs case about guns. And some gun rights activists got a law passed in florida that forbade physicians from asking their physicians whether they own guns, maybe they use guns. As part of a checkup they might say are you wearing seatbelt, because accidental gun discharges and suicide by gun, those are legitimate Public Health issues. So anyway, the gun lobby didnt like the fact some doctors were asking people about guns and they thought it was an invasion of privacy so they got a law passed that said doctors arent allowed to ask people about guns. So, of course, a group of doctors brought a lawsuit and said, look, the First Amendment protects my right to have a conversation with a patient. And that just because were in a doctorpatient relationship doesnt mean we have completely surrendered our free speech rights and the government can tell us to do and say whatever we want. The 11th court of appeals said no, even if its just a conversation, youre not touching them, doing anything, that is conduct to which the First Amendment doesnt apply. You may notice that the medical marijuana issue is kind of a liberal issue, right . And the ninth Circuit Court of appeals on the west coast, kind of a liberal court. And on that liberal issue, the liberal court decided the First Amendment applied. The 11th circuit is kind of a conservative court. And this was like a pro gun thing. And wow, coincidentally, the kind of conservative court decided the First Amendment didnt apply when it was a conservative issue. But we have a square disagreement among the federal courts of appeal, a disagreement that was exacerbated by the decision in the vet speech case that just came down so the Supreme Court actually has to step in. And the Supreme Court is going to have to decide whether or not the First Amendment applies when there is a conflict between occupational licensing and free speech. And so were in the process right now of writing our petition to the Supreme Court in the vet speech case. And this is actually the perfect case. Because whats going on here is you have ron hines, talking to people generally speaking on the other side of the world about animals. Thats it. Theyre exchanging emails about animals. So this isnt even the most intense telemedicine context you can imagine. This is right at the edge. So if the First Amendment is ever going to apply to protect the free speech rights of licensed professionals and their clients, then it is going to apply in the context of ron hines case. And this is the perfect clean case for the Supreme Court to take. The other thing too, there are some cases making their way through the court system right now that have to do with whats called reparative therapy, providing psychological counseling generally speaking to minors who are gay or say theyre gay and their parents dont like it and send them usually to christianbased psychologists. And there is a movement that says the First Amendment should protect the right of therapists to engage in gay conversion therapy. Now, one of the great things about the ron hines case is it is just about people talking about animals. Its not about gay rights, not about guns, not about medical marijuana, not the hot button cultural issues. It presents the case perfectly in a benign context, where the Supreme Court can address the First Amendment issue without worrying about making collateral statements that might have ramifications. So fingers crossed, well try to get the Supreme Court to take the case and perhaps this Time Next Year well get a decision that will tell us to what extent the First Amendment applies to occupational licensing and this will have implications far beyond the practice of veterinary medicine, scholarly, law, all things that can be done as a result of the internet. So thank you. Thank you very much, jeff. Its fascinating case, and i will keep following it, and i wish you the best of luck with it. Thank you. Im hoping for a Supreme Court decision to hoping it goes a certain way. Even if it doesnt, something fun to talk about. So lets go to our last speaker now. Josh sharfstein and ill turn it over to josh. Thanks so much. I really appreciate the chance to be here. I appreciate the invitation from simon. And i thought both presentations were terrific. Really interesting. Im a little bit in the sesame street segment, where they say which one doesnt belong and youre supposed to pick it out. Thats me a little bit in this panel. Im a physician, not a lawyer, like the other three panelists. Ive been appointed to city, state and federal positions, by democrats. And so im coming from a slightly different perspective. I do appreciate that catos internet password is obamacare saves lives. Im just kidding. Thats not true. I thought that was changed yesterday. Now its just a little joke there. So i i actually started reading simons paper and i was like, i dont think theres going to be a thing in here that i find attractive. And i just found the paper absolutely fascinating and interesting and provocative. And i thought that both of these presentations were also very interesting. And theres a lot to agree with about the points that have been made. And let me just say that for me, telemedicine kind of struck home when i was visiting a rural hospital and they showed me a ward where the patients were being entirely managed by a remote team of physicians. So there were it was intensive monitoring. It wasnt like your phone calling a doctor and showing them your rash. It was a hospitalized you know, situation. And i never had seen anything like that before. And they go, well, actually, theres a doctor watching all of the monitors. And we have one nurse or a couple nurses here that will get a call from that doctor if there is an issue to check on. Its better if there were a doctor asleep down the hall. And i thought is this a good thing, is this not a good thing . I couldnt get my head around it and whats the best way to regulate it. I think when it comes to telemedicine, its a similar question as a lot of things, which is what is regulation. Is regulation sort of red tape protectionism that hurts consumers, and just keeps things from happening that would save lives, or is regulation necessary to prevent exploitation of patients and consumers and protect the Public Health. And the answer oftentimes, having worked with Different Levels of government, is yes. Its both. And theres no simple one or the other, and it depends how well its done. And the key is figuring out how to strike the right balance. In this case i would say you see with professional boards, there absolutely is protectionism out there. My last job, i was responsible for more than 20 professional boards of different kinds. And i was called on to mediate when the doctors and nurses fought or the nurses and the dentists. There was a huge fight in maryland between the physical therapists and the acupuncturists over dry needling. Dry needling is what physical therapists want to do, but acupuncturists say thats unlicensed practice of acupuncture. And i decided at one point to do a Public Comment period. And usually we do 100 comments. Its a lot. And i got over 1,000 comments on all sides of the issue. Very revved up. I picked up my 8yearold from school, and hes like, you know, dad, whats dry needling . And i said why do you ask that isaac . And he said well, because my gym teacher gave me this letter to give to you. So just i used to say that its not a safe place to be between the dry needlers and the acupuncturists. And at one point i proposed legislation in the state of maryland that would take these scope of practice disputes out of the medical boards and all the litigation, give them to a give the ability for the legislature, just the ability for the legislature to appoint a committee to resolve it in the Public Interest. And the line out the door of all the lobbyists who were testifying against that bill was an image i will keep in my mind. Nobody wanted that. They just wanted to battle it out. So i do i absolutely concur that there are you cannot assume that just because the medical board or dental board or a different board has a particular policy its going to be the right thing for the Public Interest. The flip side is, they do provide very important Public Health protections. And particularly when people are sick, theyre not your economics 10 wellinformed consumers. People who are sick are very vulnerable. There is an unbelievable record in the United States of people getting taken advantage of when theyre most vulnerable, when theyre sick, fraudulent cures, things that hurt them. And it is very much the case that medical boards, for example, protect the public for against physicians who are quite dangerous. As do the other boards. And i used to interview i interviewed all the medical board candidates and we set up a president for interviewing all the other candidates and i said i only have two questions. Number one, will you put the Public Interest first, even if its about people if there are people out there who shouldnt be practicing, it is your job to get them out of circulation and to make sure youre protecting the public. And number two, be reasonable on scope of practice issues. Because you know, the fights that happened were just totally allconsuming when they happened. So how do you draw the balance when you have regulation like this . You know, if youre not going to be someone who just thinks all regulation is wrong and if youre not going to be someone who thinks all regulation is right and some things that make sense and some things that dont. How do you do it . How do you maximize the benefit and minimize the risk of a regulatory approach . And the answer is, you have to set up an approach, a process, that has the Public Interest as the bottom line. And i dont think that the boards themselves can really play an effective role in that. I think there are some state models that bring in external people to think those things through. That those are good models, as youre thinking about global models, figuring out what would where are the opportunities to do things that really are in the Public Interest to get the you know, its not just, i think, what simon is putting on the table isnt just that theyre u. S. Health professionals treating people around the world, but people in the United States could log on and get a consultation somewhere else. Well, that may well make sense for certain things. And there could be a system set up that maximizes the benefits of that. But also minimizes the risks by having an assurance or partnership between different regulatory entities. I think thats the right conversation to have. I think that on the basis of evidence, on the basis of logic and best practice, you can pull people together, and ive seen it. And ive even seen it on very controversial issues. We regulated abortion facilities in maryland. When we came out with our regulations, we had the right to life groups and prochoice saying we had done a great job. We were as transparent as we could going into the thinking of that. I really respect jeffs position on the First Amendment and how it relates. Let me just relate to that for a second. In my view it should be the Public Interest that is the north pole. It should not be an ideological view of the First Amendment. At first i thought jeff was saying, look, if its speech, ive got to allow it. But he is saying its just whether the First Amendment is applied. Im familiar as a pediatrician with a case in florida about guns. And i do understand the fact that there is there are speech considerations. I think if there were a way to say yet there are balancing tests. Im more interesting in, well, whats the balancing test that you apply. What is the balance between state Regulatory Agency and individuals in this regard. And i think the balance has got to be something assessment of the Public Interest, whether it makes sense. I would make the case as a pediatrician and my professional association that it can be very important for the very reasons that jeff said. And the standard applied is not just are they words coming out of someones mouth. On the other hand, on a theurp that has been totally discredited by the profession, that such as reparative therapy that has no support within organized and evidencebased medicine that the Public Interest wouldnt would favor a regulation in that area. For me i could see there is a yardstick that could be done. Its not so much whether the First Amendment applies or not but how then you would apply appropriate test that maximizes the association and minimizes the risks. If we all set down, we probably could work out that its totally reasonable for someone to be sending cat advice to the world and Something Else may not be reasonable at all. How could we draw lines that could lead to better health, lower costs and a interesting progress as Technology Evolves in health care. Thank you. Well, thank you, josh. Thank you to all the speakers. They are all great presentations. I want to open up to questions now. Let me take the opportunity to ask the first one. So just start getting yours ready. I dont mean to put you on the spot. Others, feel free to answer it too. Mostly for you, renee. I dont know to what extent you have thought about this. There are International Aspects to this. I just wonder as we all know, the United States is not the only country in the world. Other countries are doing this too. Ray, are there other examples of what the European Union is doing . It just seems eventually someone will be trading these services internationally. If the u. S. Is going to put up barriers, well be the only ones and the rest will go ahead in some way. Do you have any idea what the rest of the world is doing with this right now. We are all sort of in the same boat. We are resting on political, clinical and other issues as well. I will say in the eu, the licensure follows, which is greater access to care. Physicians dont have to worry about being licensed where the patient is located. A lot of other areas have not yet had the fully developed regulatory approach. Now, one thing i will say is is sometimes i tell my clients have you thought about starting this somewhere else outside the United States where you have fewer regulations to worry about, where you have fewer Political Considerations . I mean, we heard about the board. And i think the doctor sort of alluded to this. There is protectionist boards as well i think generally were all in the same boat. I would say given the way our laws are are enacted, the way regulations are promulgated the subregulatory guidance we have both at the federal and state level. All the various boards you have to deal with if you have a regional and National Network in mind that you want to develop, its hard to do in the United States. Let me open it up to questions. Raise your hand if you have a question. Wait to be called on. Wait for the microphone so everybody can hear the question. Announce your name and affiliation. The question now is how are you going to do or what should be done in the medical sector or public citizens complain. One is like hacking or information of the internet or some kind of obstruction basically. You have a regulation. But theres also a trend even more related to the operation. They are now promote occupation without determination. It is very subjective. And the people complain to the Government Agencies and they ignore the complaint really. What they say is is they are not in the best interest of the public. So how are you going to regulate a Government Agency in the profession of health care . Go ahead, josh. To your first point about security. I think thats extremely important. And i think that is a potential role for regulatory standard. Because even if you could work it all out. There is a great dermatologist in germany who is perfect for your kind of rash. And everybody believes its important to do over. But suddenly www. Simonsrash. Com shows up and your picture is there because its been solen is not a good outcome at all. I think enforcement of standards so everybody participating is at least able to have some kind of confidence about privacy. I think thats a really good point. The issue about medical board jobs are very hard. Because some of the things are very easy. Some things have been horribly done, horribly wrong. There need to be clear discipline. Or someone even losing their license. A lot of them are in a great area. And its very important for boards to be as property as possible. At least at a certain level be transparent about its approach. And recourse for both the provider and the patient in the case of a totally egregious decision. But there is enormous authority. I saw many who thought they were being unfairly by the board. And very unhappy patients who felt they were mistreated. You cant get involved in every case. You have to appoint good people, orient them as best as possible. It is sort of like a judge has to make a tough decision sometimes and then there is an appeal. In this case you have to think of the board being run well, as well as there being some opportunity in certain circumstances for appeals. Do you think anything about the Security Issues . Security issues are very important. We have other laws and other requirements. The eu has a sophisticated regime. While securities are important issues, i think they are addressing a myriad of security laws that most have. Question in the back. Start with the way back. And a couple in front. Nearby. Coming up on American History tv in primetime, the history of journalism in america. Next, women reporters discuss their experiences in covering the vietnam war. Then the long of lasting weekly magazine the nation on its 150th anniversary and then later a conversation about the cia and the press. Youre watching American History tv on cspan3. Cspan is in des moines for the iowa state fair and road to the white house coverage of president ial candidates. Our live coverage is on cspan, cspan radio, and cspan. Org as candidates speak at the des moines state fair. Heres the schedule. Rick santorum at noon, followed by chafy at 12 30, and senator Bernie Sanders at 3 00. And on sunday afternoon, republicans ben carson at 5 00 and George Pataki at 5 30. Cspans campaign 2016, taking you on the road to the white house. Each week American History tvs reel america helps tell the sorry of the 20th century. April, 1964, american and Iranian Armed forces conducted a series of joint military exercises designed to send a cold war message to the soviet union, which then shared a 1,400 mile border with iran. Exercise dell war in the big picture, produced by the u. S. Army. It is a persian word meaning courageous. The United States and iran were allies from the time of a 1953 british and u. S. Experted coup detat until the overthrow of the shaw in 1979. Iran is a distant land halfway around the globe from the United States. Nevertheless, its security is a vital concern to our government. As a member of sento, the central treaty organization, iran is an important link in defense of the free world. She shares a 1,400 mile border with neighboring russia who for centuries sought a water port in the area. Although iran has a fine arm with good morale and high level of training, she would require immediate assistance from her allies in case of invasion by numerically superior forces. In order to prove the feasibility of airborne support should such an eventual ality occur, the United States and the iran have a joint exercise called delawar. This successful far reaching exercise is the first of its kind on this scale. As cyrus said, my fathers kingdom extends far to the south where man cannot live because of the heat. And northward to where he cannot live because of extreme cold. This is still almost as true today in iran as it was at the time the country bore the name persia. High mountains, green valleys. And vast desert areas make up the land of iran. Here is the scene on one of the worlds earliest civilizations and the average logical remains of once great kingdoms which flourished in the ancient world. In ancient times, even as today, irans strategic position has tempted invaders and covetous neighbors. During recent years, iran supplies have been trained by the United States. As a part of the freedomloving world. 6,000 years of recorded history were to be part of the study for the combined u. S. Iranian Military exercise delawar. The planning nerve center for exercise delawar was located at mack Dill Air Force base, florida. They commanded all United States forces participating in the exercise with the compensation of mass airlift forces. Command of these forces were retained by the mats commander. In new mexico, Fighter Pilots were briefed on their tactical support mission. Two squadrons of f100 super savers were assigned to the delawar operation. 88 United States base transports provided the airlift requirements necessary to move a brigade 8,000 miles to its destination. At forth campbell, kentucky, the 101st airborne division, screaming eagles, supplied an air brigade for the joint task force, coming quickly to the aid of a friendly middle east country. Delawar is a persian word meaning courageous. Mats, military air transport from Fort Campbell to iran. In addition, 550 tons of cargo to supply the approximately 2,300 Airborne Troops involved in the exercise. Giant transports lowered their rank to take in the necessary work tools of todays modern fighting man. Jeeps, artillery, communications equipment. All were loaded in record time. These items of military material traveled thousands of air miles together with the soldiers who would use them, demonstrating to our friends and other nations the mobility of the United States armed forces. Also present at all times during the delawar exercise was the tactical fighters. Strategic air command kc135 jet tankers refueled the tac fighters en route from the United States to iran. Eventually a base in turkey was the first stop where the battle group won their trap. Eventually air base, elements of the delawar operation awaited dday go order. The troops remained during their stay by tough battle exercises. Of course, like soldiers everywhere, time was found for that moment of relaxation. Yhun and a chance to nourish the inner man. Meanwhile, in neighboring iran, elements of the iranian royal guard assisted by United States military advisers staged a warmup. Iranian fight crews and airborne officers went over the operation plan and pinpointed the drop zone area. The confidence and skill of these men testified to their qualifications as paratroopers and the excellent training given them. Now all was ready for the exercise itself. On dday, the air brigade took off between turkey and northwest iran. The brigade conducted an assault. Later during dday, a navy force conducted an Amphibious Assault. They were supported by jet fighters. In iran, exercise delawars nerve center at the air base. Among the first to land were transport carrying the joint task force staff. Communications equipment and personnel also arrived on these aircraft. Setting up with the speed and skill only from long hours of training our Communications Network was soon established. The first combat elements to arrive in iran were the f100s, which landed with routine precision despite reduced visibility. United states and Iranian Air Force officers were on hand to observe the landing. Also on hand for the big picture was Sergeant Major donald cosgrove. 4. Were down on the plate line here at the air force base. Why dont we have time prior to the massive air drops taking place. Were going to speak to a couple of the military personnel involved in exercise delawar. One of the most interesting things about this exercise is that for every american participating, he has his iranian counterpart. In just a few moments this fighter jet behind me will be taking part as part of the air cover for the airdrop. And i have standing to my right a Second Lieutenant jet pilot of the imperial Iranian Air Force. This is Second Lieutenant hajazy. I would like how you feel about taking part in an exercise with the american pilots. I would like very much to take this exercise. And i think america will bring some memories for my flying time with the United States. Where did you do your flying, sir, in the United States . Well, i got my primary and basic training out of lubbock, texas. And my gunner training in las vegas, nevada. Lieutenant, i must say i notice one thing about you. You speak very good english. Did you have to take any Language Training . I got about four months of Language Training out of Lackland Air Force base in san a antonio, texas. And the gentleman to my left is major stallings. How do you like taking part in exercise delawar. Sergeant, its a real fine opportunity for me because one of the jet pilots in the squadron is an old student of mine from the United States. On dday, just before the first airdrop in exercise delawar, his imperial majesty, arrived with his staff and aides at the reviewing stand. Among dignitaries were representatives of england, pakistan and turkey. Observing an exercise designed to prove the effectiveness of cento armed forces. At exactly h hour, the first wave was seen over the drop zone. Heavy equipment was dropped first. Then paratroopers of the 101st jumped nine miles north of the iranian city of desbul. The clusters filled the sky in this first jump of the threeday delawar exercise. Once on the ground, the soldiers scrambled, regrouped, and later joined their iranian cam rods in arms holding a line to the north. After the drop, Sergeant Major cosgrove talked with the exercise commander. General adams, im happy to say once again our paths cross. Only this time halfway around the world, sir, in iran. Neighbor to the command just mentioned, general adams has another command. Will you explain that command and what does it involve . It involves a military, u. S. Military responsibilities in what we call the middle east, south asia, and africa, south of the sahara. And discharging these responsibility, all are brought under one single commander. This exercise is under my command because i bring the forces over and turn them over to the man who conducts the operation here. Germ, you have had the opportunity to meet and talk with his majesty. What were the shaws impressions of exercise delawar. So far the shaw has suppressed great pleasure over what has taken place in the exercise. Just a few moments ago he turned to me and said that is a very precise drop indeed. And there is enthusiasm in the manner in which he suppressed himself. Sir, do you feel this exercise will have some kind of an impact on the iranian army and, in fact, on the iranian people. I think any strong, common endeavor between two people does have a large impact. The impact is one to start with. But most importantly is that we are learning how to work with the Iranian Armed forces as a combined joint team, engaged in a common enterprise. With this teamwork, if we should ever have to operate together, our strength will be multiplied. As the first Airborne Assault was successfully concluded, the shaw left the stands in order to follow the action as it developed. He boarded a jeep and joined a convoy of ig tears for u. S. And Iranian Ground forces. We are now 250 miles. Or as they would say in this part of the world, about 400 kilometers from the air force base. It is a sunshiny, but still breezy day. As we stand on this hill overlooking the blue waters of the persian gulf. It is still dday, hr plus 3 to be exact. And the Amphibious Assault is well under way. This operation is still a part of exercise delawar and is designed to point up the ability of the United States military establishment to deliver Amphibious Support to our allies if and when they should ever call for it. A United States naval force of two destroyers, one reinforced Marine Company and eight helicopters took part in the action
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