Transcripts For CSPAN3 Politics And Public Policy Today 20160418

Tuesday night for the new york state primary. Join us at 9 00 eastern. Taking you on the road for the white house on cspan, cspan radio and cspan. Org. President obama delivers his last speech at the end of the month and this coming weekend they take a look back at the previous dinner routines. Heres a poerth of what you will see. No one is prouder to put this birth certificate matter to rest than the donald. He can finally get back to focusing on the issues that matter like did we make the moon landing. What heal happened and where are big e and tupac. All kidding aside. We know your credentials and breath of experience. For example, just recently in an episode of Celebrity Apprentice at the steak house, the Mens Cooking Team did not impress d andy recognized that the problem was lack of leadership and you didnt blame lil john or meat loaf. You fired gary busey and these decisions would keep me up at night. See the speech saturday night at 10 00 eastern on cspan. The program also includes remarks by senior White House Correspondent and this years correspondents is saturday april 30th. They take you there live at 6 00 p. M. Eastern. Its one of the biggest social events in washington and its president obamas final one as president. It also features larry will more of the nightly show. The National Lieutenant Governors Association held the meeting to examine ways to advance federal state relations. This portion included key note remarks by the oil and gas Strategic Marketing director who outlined oil market trends. It has been a half hour. Good morning and i want to thank you. Nationally they were known they caused great pressure on the state budget. We love to fill up the personal cause with the low gas, but the low gas prices if challenging times in our state budget. Here is insight on the oil and gas Market Leader and you top the join us up here . Thank you and good morning. Its an honor to be with you today. Thank you for the time. My name is allister and based in london and i lead marketing for the oil and gas business. For those of you who dont know, we are a large part of general income that plays across the value chain providing services and development from the upstream through the downstream. About 39,000 people around the world and about 11,000 in the u. S. Big facilities in houston and boston and Oklahoma City and the west coast. This is clearly a big issue. Whats going on in the industry at the moment. This is where i live and breathe and i think about this every day. Just for a few minutes i wanted to share our thoughts on whats going on in the industry and hopefully give you ideas about what it might mean for your states and how collectively the industry policy makers can help to get through this in the best way. So the first thing to say and this goes without saying, no one really knows whats happening at the moment in terms of production. Its highly uncertain. Its very, very uncertain. So what i am not going to do is tell you what the oil price is going to be on december 31st. If we have learned anything over the past 18 months, people are bad at predicting that. So what i will try to do is share with you thoughts on what is driving the market. What it means for us and also what it means for you. In terms of tact and employment activity in your states and hopefully share the way we are thinking about this and give us inside about how the industry can move forward. People talked about the return to the 1980s and this crisis is caused by too much supply. That is what we believe. This is not a demanddriven crisis. There is too much fly on the market and that caused the prices to come down. The last time that happened was in 1985. After 1985, industry spending, industry activity stayed down for about a decade. If you look on the graph, you see the red line down at the bottom shows the current cycle with the peak oil price. We are way below all the price of cycles and 1985 in terms of where we are today. There signs of pt michelle will. They bounce back in the last few weeks. Up more than 50 from the low earlier in the year. Any normal environment you think is amazing. The low was so low. Bah the fact that this is a supplydriven issue means that we do not think this is going to come back rapidly. We dont think 100 oil is good planning assumption any time soon. We expect it to come back slowly. The general view i think most people share is that the oil market will start to come back to balance towards the end of this year and that will translate to activity and spending by producers next year. Clearly a lot of factors are at play. The supply and whats happening here in the u. S. And other parts of the world. There is demand. Snnlly demand is okay, but there concerns about whats happening in china and they may reduce noble demand. Particularly now that the ban has been lifted here. They are competing in the world market. And more financial play in whats happening at the moment than there was in the 1980s. If you look at the trait market which is financial rather than physical. All of which is to say i guess like you, i hope the market is going to start to come back this year. There lots of factors at play and we cant make any predictions. What can we do . What we need to do is give our business guidance and what they do. They have to make decisions about capacity and planning and how they deal with customers. You see on the graph, there is an enormous range of predictions about whats going to happen in terms of price. If you look out to 2019, estimates of the market commentators range from 60 up to about 100. That makes a huge difference in terms of whats going to happen with production. I dont know where thats going to be and when you are thinking about state budgets, you dont know either. What we are telling our business is think abouty is narios. And in particular, we are giving the two on the right hand side. We hope it will be a slow recovery. If the price stays down about 50. What would they do . In every scenario we are asking them to focus on the things we can control. Ge is a big company. But we dont control the oil price. No point in worrying about what the price will be. We can focus on the things we can control. If you hear them talk about this, you hear my ceo talk about this. The constant mantra. The things we can control in serving our customers to get through this. They are suffering at the moment. If we can help them to get through, they will remember that and its good for the industry as a whole. Its good for us. Now, with that said, we have a view on whats going to happen. In the near term, this is what we think is going to happen in 2016. Its not a pretty picture. Particularly for those of you who have a lot of onshore and nonconventional activity. We are expecting spending in the upstream to be down 30, 40, 50 . Thats on top of similar reductions last year. By the end of this year, spending could be down three quarters from what it was in 2014. Thats an enormous reduction in some places. In terms of production, again a wide range of estimates, but the production as a whole could be down a Million Barrels a day. Thats a good thing in terms of returning to balance. Not good if you think about the royalties, but thats a good thing. The most important thing i think i said at the moment is that our customers, the operators, many are not making decisions based on break evens and they are making decisions based on cash and preserving cash and preserving their credit readyings. That is how they are behaving and they will make divisions about relations and whether to complete them based on can we keep the Company Going . Can we maintain the ratings and avoid bridging our debts so that we can come through to the other side. To be looking at the rest of the world, it doesnt help you guys quite so much. Its not as bad. Its down everywhere. Middle east is the one place where they may be growing this year. Then offshore it is also down, particularly in the gulf of mexico. For lightly different reasons. They started when the oil price was well over 100. The industry has been getting so expensive. To give you an example, every year we have a lot of customers come to talk to us in florence, italy where we have a big facility. Last year one of the Senior Executives put up a chart that showed two very similar facilities from i think from the gulf and maybe from the north sea. He said we built this in 2000 and we built this in 2013 and they do the same thing. The one in 2013 costs 2. 5 times as much. Now, some of that is general inflation and some is the price of steel. Some is what i call good regulation, safety, environmental concerns. Some of it is either bad regulation or internally generated gold plating by the companies themselves. Not mandated by the tell us makers that has just increased the cost. The great example that someone gave me was you decide that you want a covered walkway from the mot ul and in the past its a walkway and people put on their jackets. You cover it. Then you have to provide heating and air conditioning and you have to increase the power and the weight on the gas turbines hopefully from ge. You increased the weight even more. You added thousands of tons of steel and more power capacity. Thats expensive. You think we have to manage that. Thats the shortterm. The back to fundamental economics. But thats what theyre doing. You know, i was at some of you may have been there, the Oil Ministers of saudi arabia said clearly, let the market decide. Now, if you look at where north American Resources sit on the coast, on lefthand side, we have a view of the cost curve of production in 2020. Existing resources were actually pretty well placed. So theres a wide range, but if you look across the ranges, you say, well, onshore, unconventionals, u. S. , canada, break even in the 30, 40 range on average today. Some are lower, some are higher, and thats okay. That competes pretty well against the rest of the world. Its not too bad, versus even the middle east. Current gulf of mexico deep water breaks even between 20, 50 a barrel. Thats pretty good. Thats actually better than many other places around the world. Speaking as a brit, the north sea has huge challenges at the moment because its much, much higher for them. The problem for north america comes when you look out and say what and about new production . Unconventionals where the decline rates have so great year in year. If you look out to new fields that are forecast to be producing in 2020, you see those breakevens go up, unconventionals 40 to 80. For the gulf, 35, 75 a barrel. If we are in a world of 60 oil in 2020, a lot of those developments have problems. So as an industry, we need to think about how to bring those down. Now, a lot of the focus, and in recent years, its been about getting pricing out of the supply chain, increasing productivity. In the onshore price, total cost to develop barrels has come down 20 , maybe 30 . Its theres a little bit more to go. Offshore has been a similar journey, its slower because the projects are bigger. How do we keep that going . Its something the whole Industry Needs to focus on. We need to focus on it, customers need to focus on it, you know, and there are roles that your organizations can play in terms of thinking of regulation, taxation to optimize the benefit for the state as a whole, which is partly taxation but also the employment and activity that goes with it. Now, lastly, looking out, a pretty gloomy picture. But why do we still like this . The answer is that, you know, we at ge like the industry because we think, for all of the shortterm uncertainty, one, its not a surprise to us, cyclical industry. Weve all known than cycles go down and then they come back. But more importantly, this is driven by the worlds need for energy. Its a global market. Around the world people continue to get richer, they move to cities, they need more energy. You have to supply that from somewhere. If you look at, you know, the big source of Production Growth in recent years, opec, deep water, and north american shale, you can get to meet demand after 2020 from two of those three, just about, if you make some assumptions about china slowing down. Theres no way you can meet that demand in 2025. You will not get there our view is to get to 2025, the amount of oil and gas the world will need, you need all of those things. As an industry we have to work out a way of making them happen. So, thats why we still like. Thats why were still investing in the industry as ge. We particularly like gas as well. We believe that gas is a major fuel of the future, gas demand is growing twice as fast as oil, and lng is growing another two, three times on top of that. The u. S. Has become an lng exporter. That is going to be a huge driver of future energy consumption. So, what does that mean . Red lights flashing, which fits at the end of the slide. So, just to final thoughts, innovation and productivity are critical here for all of us. I invite you to think about the role we can play. We like to a partner to our customers but to regulators, states in thinking about that. We need to get costs down, because low costs resources will win. But that does not mean abandoning a focus on safety and the environment. We have to keep the license to operate. You know, theres lots of noise about the oil and goose industry at the moment. We must keep a license to operate. We cant relax that focus. But nor can we plan on the basis of a rapid return of 100 a barrel of oil. Were confident this industry has a lot of legs and for many of your states will continue to be a major driver of employment activity and taxation. Thank you very much. [ applause ] we are all hoping wed here its going to be 100 next year. Any questions . Thats a first. Well, weve got a great mixture of oil and seafood in louisiana, so we balance it well. Of course, with the oil spill, we balanced it too well. Id like to keep it separate. But i have a Great Respect for the balance between energy and the environment. So im pleased to introduce General Electric paul due set to present National Water Energy Environment stewardship. Its always fun to be around the louisiana governor because theyre the only person that can pronounce my name right. I am, again, honored to be here as always. This is an annual award for us. I believe this is the sixth year that by the way, thank you to the Lieutenant Governors Resolution Committee yesterday for recommending at least the renewal of this partnership between General Electric it lieutenant Governors Association. As alley staistairs alluded to, award is designed to try to capture in some innances an individual policy initiative or a particular piece of work. And in other cases a more career oriented commitment towards the energy and the environmental balance. All right . Its clear, i think, from what ali did stair said and the things that Lieutenant Governor alluded to, that energys really important. While we all love cheap energy, you know, there are jobs and other consequences that are associated with that cheap energy. But were concerned about the environment and how far you go along the continuum thinking about the environment does not negate the reality that there is a balance point. There is a place for Getting Energy right. And so this award is designed to reach out and try to highlight examples of in this particular case, work in natural gase that has helped get that balance right from rely from state revenue perspective. So we take nominations from almost anyone who is willing to nominate a Lieutenant Governor to receive the award, and we go through evaluation, in this particular instance, recognizing Lieutenant Governor who has seen both the energy and the environmental benefits that devolve to their particular state in using natural gas as a transportation fuel. Recognizing and trying to promote and encourage the use of that natural gas for state fleets, state vehicles, state equipment, to capture both the economic benefits, the jobs benefits that flow from the production of natural gas and then also the virenvironmental benefits from using natural gas rather than alternative fuel. Im pleased and honored to present this award this year to the Lieutenant Governor from the state of texas, dan patrick. I will be very brief, because lunch is around the corner. Our initiative, and a campaigned on this in 2014, to begin converting our government fleets to natural gas vehicles. T. Boone pickens, many know that name, famous oilman, has been trying to push washington on the same issue. One of the things he taught me was, dont focus on consumer vehicles. The consumer vehicles are a long time down the line. But as more companies, like u. P. S. Is changing to natural gas vehicles for their trucks, more companies and Government Entities eventually move to natural gas for fleets and vehicles, eventually consumers follow as they drive those vehicles at work. We have 31 senators, 20 republicans, 11 democrats, and as Lieutenant Governor i assign bill numbers. The top 20 bills are reserved for my priority. I assigned this as bill number 12. And asked a democrat from san antonio to carry the bill. Who had compae to a natural gas summit i saw in the audience a year before i was elected. He wanted to carry the bill. Its and a bipartisan effort. All of the states, 28,000 vehicles, not counting Law Enforcement vehicles, 28,000 vehicles that through attrition over a decade we could replace 75 of the vehicles. It would have saved taxpayers millions. It would clean our air. And it would have created jobs. When i decided to push this legislation, i immediately went to the oil industry, and went out to midland, texas, met with the oil industry to make sure producers and drillers were on board. Not everyone was on board but id say 90 of the people were on board from the oil industry. The refineries were not in favor, honestly, you have resistance from them. At the end of the day, the bill passed out in the senate 283, you may know paul, i forget. After passing 1262 bills you get lost in those votes. I do remember that one. I appreciate the award. Its something we need to done its a part of the future. We always are going to need oil. Its very important to our state, a major part of the revenue. Natural gas can be a major part of the revenue as well and since its so cheap. To give you the equivalent, when gas was 4, if you put natural gas on the same equivalency of gasoline you would have been able to fill your tank equivalent for 4 about 1. 80 a gallon. Saves consumers a tremendous amount of money. Our bill, by the way, set aside 35 million so we could we made this a policy for the state but we allowed local governments, School Districts, and others to opt in. So we didnt force it on our School Districts our or city fleets or county fleets but they could opt in. 5 million to be 35 million to be used to use stations. One of the things that t. Boone taught me was to maybe this work, you have to have a hub because its just we have 150 natural gas stations in the triangle but you need a hub. When the truck goes out or bus goes out, theyre coming back at end of the day to refill so you dont have to have stations. Eventually theyll continue to grow. That was the thinking, to a School District or county government, where your vehicles are coming back to the yard at the end of the night, you have your hub to refill. And so thats what were go to do with our 35 million. Its about 1. 5 million to create a natural gas station, hub. We knew the program would be successful over time, wed add more money. Thats the program we pushed. We thank you for recognizing it. We didnt do it to win an award. We did it because we thought it was a good idea. Thank you all very much. Julia . If we could proceed. Thank you all so much for everybody. That was our break time, to proceed to the break area, down the hall, to the right. If our award wry accept yent and presenters and stay for the fogter to. Winners today, phil scott, sharing great thoughts, bringing engaged leaders together. And jim wood of the Steel Recycling Institute for being consistent in his photographic and content contributions. Stop at registration desk. Well see you back here in 30 minutes. 30 minutes. On the eve of new yorks president ial primary, Donald Trump Holds a Campaign Rally in buffalo, new york. Live coverage tonight, 7 00 eastern on cspan2. Madam secretary, we proudly give 72 of our delegate votes to the next president of the United States. A look at innovation and the biopharmaceutical industry and how new drugs are applied to test and treat diseases such as alzheimers. Speakers include representatives from the drug industry and research groups. This hourlong discussion part of the annual meeting of the nations Lieutenant Governors here in washington. Okay. Good afternoon. Welcome back. Usually after lunch we fall asleep. This panel will keep us alive and kicking, especially because we have jim n. Hendricks as one of the panelists, you know. I just want to say its a pleasure to always join my peers here at nlga and the conversations are always inspiring and enlightening and it is good to every once in a while hear from experts in their areas and, you know, they give us a chance to keep the dialogue going and get the conversation and the debate, you know, ongoing. Folks from nrga, we have partners and the Partners Program that will bring diverse points of views and different perspectives to inform us and keep us really on the cutting edge. So i want to thank the partners. Thank you so much for being a part of this. And let me bring to the podium the leader of the nlga partner program, chris, archer dannials midland, adm. He was telling me what they do. It is really quite interesting. Welcome, crisp. Thank you. I appreciate that. Enjoy those. Good afternooning thank you for fostering these partnerships at nlga that allow Public Private partnerships to bear fruit. 0 on that, thank you to the Lieutenant Governors here. Its your program but yet we want to invest in the program. There wouldnt be a program to invest in if you didnt show up and partake in all of the conversations that we get to have together. We want you to succeed as much as you want to succeed. And we want to help you in whatever ways you need that. I think on behalf of the caps, thank you for being here. We appreciate it. With that, we had our call, our discussion, about what the topic we wanted to have this year at this meeting and it became wonder drugs. And you know, as i was talking to jim delat, its about innovation. Jim, ill give you a little plug. Having been a diabetic since 1978 ive seen a lot of innovation in diabetes alone. From taking insulin shots with bigger needles to smaller needles now on an insulin pump which changed my life. Innovation is so important when it comes to science and medicine. Im excited to hear our peek speakers. Terra ryan of the pharmaceutical research and manufacturers of america, otherwise known as pharma. I was going to say what an honor it is to be on stage with jimmy hendricks, but we feel that way, hes going to be a great panelist. Im not sure hes going to play any music. One of the most important issues youre facing at state level, Medicaid Budget is something that governors and Lieutenant Governors are thinking about every single day, Health Care Costs are rising. I want to set some of the record straight today. Its important. Weve seen a lot of focus on the rising cost of Prescription Drugs and what we dont ever hear about is how drugs are put into the context of the Overall Health care system. I have slides here. Patrick has slides. O i talk fast. I have been told i might get an electric shock if i go over. I might talk faster than i normally do. Im not very good with clickers. There are more than 7,000 medicines in the world today. We listened to what chris was saying have the insulin pump. The direction medicine is going is changing dramatically and quickly one of the biggest issues we dont know how to get our hands around new medicines coming to market. 70 of new medicines have potential to be first in class therapies, treat disease in a way no other medicine before them has been able to do. As more therapies become tailored to individuals, youve heard about personalized medicine, president obama spoken about it, states are looking into how to deal with personalized medicine. 42 of new medicines in the pipeline have the potential to be personalized medicine. So were looking at a really different world as far as health care. And i think you have to really keep that in perspective thinking about how to address Health Care Costs. We were at a meeting where one of the unsurers on a panel said there are too many medicines in a pipeline. Can you imagine that, with the value of medicines coming to market somebody could Say Something like that . There are so many disease that dont have appropriate medicines either to treat symptoms or cure them, there are a lot of patients, probably some of you in the audience and probably many Family Members waiting for something to come and treat their disease in a way that hasnt been treated before. Another thick is medicine is probably the most Cost Effective means of preventing and trooeting disease. Not only do med isnicines help people live longer and healthier lives. Weve heard a lot about that recently. We never hear when drug costs go down or how they offset other costs in the health care system. Thats one of the challenges drugmakers face. You dont talk a lot about the system but we never hear about the cost offsets. You can talk about high prices of drugs when they come to market, they make headlines. Weve heard a lot about it with and the new hepatitis c drugs, theres been a lot of debate. The problem is it takes a few years to collect data to show what the cost offsets are. And you have to be thoughtful about your approach. A new drug that comes to market will, if its a cure, hepatitis c drug, it will have offsets down the road. You have will people that dont have to have transplants, people wont suffer from acancer where they need oncology treat for a long time. A whole variety of medicines that they have to be subjected to for a lifetime. Medicines shift the treatment paradigm towards prevention allowing patients to avoid expensive hospitalations and ho longterm care which are far more expensive than drug as loan. One extra dollar on medicines with congest on emergency room visits and inpatient hospitalizations. Spending 1,058 on congestive heart medicines lowers spending by 8,000. These are real numbers, numbers you have to think about looking at how to achieve cost savings overall in the health care systems. This was one of the headlines back in the late 80 and 90s, hiv epidemic, and a lot of press about how it was going to bankrupt the system. Today we know hiv went from being ayou fatal disease where you died to a chronic disease, people are treated for it women who have hiv aids are giving birth to Children Free of any disease. The medical breakthroughs have had an enormous impact on medical cost and the economy. Nuft 1985 it cost the army 500,000 to treat each aids patient in its care. New medicines reduced hospitalizations, made them short somewhere despite the increases in the number of people with aid because people are living, the fact is we are treating five times the number of patients at the same cost in late 80s and early 90s. That is significant progress. From a fatal disease or chronic zeeer disease, treating five times the number at same cost. We let innovation work. People with aids are being treated. Mothers with aids, children are being born diseasefree. People said let the innovation work. Weve had people come in to pharma and speak to us about the different changes that theyve had as far as medical care over the course of time diagnosed at age 18, in their 40s and 50s living basically normal lives. Another thing you hear in the media that our Companies Take research from nih and charge big prices on it. I wanted to put this in context. The total nih budget, total, is 30. 1 billion. Pharma Member Companies thats not a big number, we only have 33 Member Companies pharma Member Companies, biopharmaceutical r d investment in 1420 was 51. 2 billion. So we take the basic research from nih and do the Clinical Trials and figure out how to make that work for patients to treat certain diseases. Yop you have to remember that nih doesnt just do resent for the pharmaceutical industry. They do it for academic institutions, for the department of defense, for other institutions and agencies are as well. Dont be confused think if all all of the Companies Went away, nih would be bringing new drugs to you. Even if you doubled the budget, we might get some things done faster, better research, more quickly for patients who need this. Its not going to solve the problem. You still need investment by Biopharmaceutical Companies to do research to turn basic science into something treating disease. From the perspective of people who are working in the state as Lieutenant Governors, its important for you to understand value Clinical Trials bring to the state. There are significant economy benefits that result from conducting Clinical Trials in your communities across the United States. Theyre the most time and resource intensive part of the r d process for new medicine. A report in 2013 said the Biopharmaceutical Industries sponsored 6,199 Clinical Trial of medicines in the u. S. Involving total of 1. 1 million participants and these trials occurred through the 50 United States. Theres a lot of debate, as far back as 1960 the drug span as part of the health care dollar was 10 . Act cue we it will be 10 of the Health Care Dollars as far forward as 2025. That 10 is an average. And it fluctuates. If you put in other factors of the health care system, longterm care, hospitalization, that number will increase, 14 , 15 . Its a small smar ll share of health care dollar. We hear about 2014, the big spike, its a doubleedged sword, Affordable Care act passed and in 2014 you had medicaid expansion. You had people who had access to medicines, so that helped in increase in drugs spent. An odd year, as far as drugs going off patent, we didnt have a big number of drugs going off patent. In 2014, more than 40 drug approved by the fda. A lot of things coming together in one year and the media has taken that without giving you background to explain why it happened. One of the drugs that came to market in 2014 was a cure for hepatitis c. Another thing that you dont hear a lot about, we hear about the net price the list price of a drug 84,000 pill. If i asked, anyone heard about the 84,000 pill everybody in the room will raise your hands. You never hear about the rebates Companies Pay to have the drugs covered on the drug list. This slide shows total of drugs spent in the United States commercial, medicaid, et cetera, for Single Source branded product. The blue bars represent by how many dollars list prices grew in each year. You can see that line going up. The green bar represents how many dollars net prices grew each year. The difference between the light and dark bars are rebates. Theres a significant gap. The blue line graph represents percentage change and invoice or the list prices compared to the previous year. So between 2013 to 2014, list prices grew by 13. 5 . Green line represents the percentage change after rebates, discounts are removed compared to the previous year. So between 2013, 2014, net prices grew by only 5. 5 . Net prices are increasing. But the rate of growth has declined each year since 2012. The net price growth of 5. 5 in 2014 was in line with Overall Health care spending. This refutes the argument you see in a lot of the coverage. I want to talk about the changes that our companys faced following passage of the Affordable Care act. Before the act, brand drugmakers paid basic or minimum mandatory rebate of 15. 1 of each drugs covered in medicaid. When our companies negotiate to have drugs covered in medicaid, they are also forced by virtue of participating in medicaid to participate in the v. A. Program and in the 340 b program. But before the Affordable Care act we paid did 15. 1 on all of the drugs. Following passage of the affordab Affordable Care act we paid 23. 1 . Manufacturers were required to pay rebate in fee for service programs. Following that passage of the Affordable Care act we pay rebates on all managed care lives. Majority of state Medicaid Programs are shifting their medicaid population to the extent that i think excluding some of your most vulnerable into your medicaid managed care, who is getting benefit of rebates on those lives as well. On top of that, we had medicaid expansion. Our companies took a significant hit on Different Things that they were required to do following the passage of the Affordable Care act. Another thing, i think, from a state perspective, thats important for you to understand, i think the level of understanding on the value that medicaid rebates brings to your state varies based on how much you work with your medicaid department, how much you work with your health and Human Services and health committees. The Rebate Process is incredibly complex. We have minimum mandatory rebate of 23. 1 for all drugs. In addition, we have Consumer Price index penalty. Every tomb a drug in the commercial market goes up the rate the price goes up faster than the rate of inflation, theres a penalty paid to the state and that penalty is compounded over the time that the drug is on the market. In addition to that, we pay supplemental rebates for Product Placement on your preferred drug list. We have minimum mandatory rebate, supplemental rebates. 201415 loan we paid 19. 4 billion in rebates. Look in your own state, the number is significant. I think its important component of dont forget, dont look at list price of the drug, look what were paying to have that drug covered. By the time a drug goes off patent in your state, theres a good chance that were paying more than any of the generics, almost paying to have our drugs covered on your Medicaid Program. To put drugs in perspective, spending on drugs, private insurers spent as much on medicines as on administrative costs in 2013. They spend as much on medicines as their administrative costs. Those are insurers. U. S. Will spent 13. 5 trillion on hospital care over the next decade. Now is the time to better drugs to market to decrease hospital and longterm care costs. It is the only way to fine a solution to figuring out how to deal with Health Care Costs. This is important. I recognize the redlirecognize. I was told id get an electric shock. The price of medicine is important. It is not an arbitrary number pulled out of the sky. Every company does it differently. We talk about r d costs. Youve heard about the legislation thats floating around in the stated. But they look at the Patient Population. Theres barriers in place at federal level, a product coming to market, barriers about knowing when youre going to get fda approval. There are some things we should be looking at the federal level to help states better understand whats in the pipeline and whats coming. You want some predictability. Its not looking at the r d that goes into a drug thats going to provide that predictability for you. There are other things that states should be focusing on to figure out whats coming, how you might address the newer drugs as they come to market. One theres a huge component and how insurers are going to cover the drug and what conversations and can our companies have with insurers before the drug gets approved to be launched in the u. S. And there are some barriers in the way that keep conversations from happening earlier than maybe they should. Theres a lot of discussion that can go around looking at how drugs are priced. It shouldnt be based on r d alone because in addition to the one drug that comes to market, you start off with 10,000 compounds. And those compounds get narrowed down and tested and you end up with one drug. It takes 10 to 12 years for that process to happen. Patent starts running at the time the research begins. By the time the drug comes to mark the patent is 10, 12 years into its life span. Ill end on this one, i have more slides, but one of the other things you hear about is states inability to be negotiate properly. I will talk about the pharmacy benefit managers. Its another within of the things if i said raise your hand, how well do you know what the pharmacy benefit managers do. Probably few hands would go up. Theres a whole supply chain that goes between the time a drug is manufactured and to the time the patient picks it up at pharmacy and youre the patient. There are negotiations that go on with pbms. Today, this slide is outdated. Today there are three pbms who control more than 81 of the market and those three pbms have enormous leveraging power in negotiating prices. They negotiate with pharmacies and other players but theyre the ones that do the negotiating to the official rebate prices. If you look at hep c experience, gill add is not a number one company. They came to mark, they said we dont want to negotiate, we have a great drug, ut a cure. They knew they had competition right on their heels. So they opted out of negotiating. Their initial negotiation, average rebate was 23 . As soon they had a competitor hit the market, rebate went up to 46 . Its up past 60 . Were getting hep c drugs cheaper than anywhere in the world. Thats because of the power of negotiations, its because of the competitive marketplace. Its working. Some of the pbms said dont cover the drug, et cetera going to bankrupt the system, same with the hiv aids in the 80 and 90s, they are saying its so cheap, everybody who needs it should have it. The power of competition is working. The value of innovation is working. And i think ill end on that note. Patrick, your light will start on yellow. Im kidding. Im patrick, Vice President at biotechnology innovation organization. Id like to build on what tara was talking about. Our organizations are similar. We share some membership. Bio is the pie biotechnology ar the industry. We like to say that we feed fuel and heal the world at bio. We love iowa. Thats my line. One of the differences, the profound differences is that a lot of the Member Companies are very small startup Biotechnology Companies that depend on the larger Biopharmaceutical Companies b biotechnology is a new science in biomedicine with the started to get its start in 1970s and clusters in cam bridge, massachusetts, San Francisco, California Building clusters in pennsylvania, new york, what have you. Our technology, the medicines that our companies are providing are complex that manufacturing process is complex. Its extremely long, extremely expensive. I dont know i put these out of order. Sorry about that. I have an extra slide in here we should be proud in the u. S. This country is the number one investor in research and Development Investment across the world. Europe is fol falling in its place, its lost ground to United States and asia. The biopharmaceutical industry invests five times more in r d than the aeronautics and space industry. More nan the computer industry. These are Small Companies that are being backed by a whole variety of financing mechanisms. But its based, the success of the companies is based on a lot of innovation and a lot of Financial Investment but there has to be a reward for investment. To terras point, we hear about nih doing most of the research and Biopharmaceutical Companies stealing that Technology Just for profit. We like to dispel that myth. Ni hichlt is an important partner to our company but was think of nih as building hypothesis for an idea. Responsible for the basic Science Behind product development. Our companies go in, use that basic science and develop something thats usable in a patient. But if you look, again, this number, 142 billion is different than tearras number because this includes some of the small startup Biotechnology Companies out there in the u. S. Once again, roughly 70 of the products in development are first in chase, first in class means new technologies that are not only looking at diseases in different ways but treating diseases that up until now have little or no treatment options. For things in neurology, cardiovascular disease, cancer, immewnology, hiv and aids. Id like to talk more about what are these Small Companies like. Who is behind them. These are very run by vae innovative strids. They get their funding from venture capitalists, Large Pharmaceutical Companies out there and patient groups. A lot of our Companies Receive a lot of fundings from patient groups. These are one thing in common, they recognize need for investment and they recognize their investment is risky. Reward should be commensurate with the risk, both financially but reward of providing Patient Population with a new treatment theyve never had before. In the pipeline of companies, Small Companies account for roughly 70 of all of the clinical pipeline in the industry. And they do a lot of it on their own. But 42 is partnered with Larger Companies. But the point im trying to make here, innovation is happening at the Small Company level. And were working closely with the Larger Companies to make sure that innovation gets further developed and the products get out to people that need them. Where that innovation is occurring, across the whole spectrum of therapeutic areas. The bulk of the research is happening in the small biotech industry phases in oncology, but were also roughly 9 of the research that were doing is in the rare disease space. These are diseases that impact 200,000 people or less, and that is a very important aspect to remember because the return investment on some on small Patient Populations can be a challenge. Companies have to look to see how are they going to recoup the r d investment on a small Patient Population. Companies have decided this is the space they want to play in and theyre trying to get treatments to conditions and diseases that for very small Patient Populations and thats usually in biotech space. Thats where that slide went. Another point that we like to dispel is a lot of people think big, Large Pharmaceutical Company were loaded with cash, very big, were profitable. That is a very small portion of our industry, 90 of the companies that we represent in bioare not profitable. They dont have a product in the market. They are living daytoday with precarious financing, theyve got to reach milestones and Research Investment to get the extra dollar. It important when we talk about the industry that theres risk, so much risk associated with bringing a product to market that a lot of the companies that we represent in bioare not that profitable. It take is along time for them to get a product on the market. Finally, policymakers, i want to make, you know, a very important point that you know we hear a lot of rhetoric about the industry thats not thats very antiindustry. That rhetoric has consequences. We have noticed in the beginning of the year that the biotech segment in the biopharma world lost roughly 3 billion in market share from the beginning of the year when we started seeing tweets and posts from some president ial candidates about how they want to place price controls on the industry. Thats an example of comments being made by policymakers that will have a tangible and oftentim oftentimes negative impact on industry. Today, the biotech industry, compared to other industry sectors, they are starting to climb out of the slump in the market that we had in the first quarter. And the biotech industry is not there yet. Theres a fundamental fear among the Investment Community there may be policies that are enacted that have a profound and bad impact on the future growth of the industry. I want to leave you with that point. As policymakers you have a profound impact on the success of this business and the u. S. Is the heart of the biotechnology industry right now. Thank you. Thank you. To discuss what medical innovation can mean to one disease, if it hasnt impacted all of us, either most of us, a love one, a friend, someone that we know. Welcome our final speaker. Leader of scientistic efforts for the amount heilAlzheimers Association, james hendricks. When you heard Jimmy Hendrix was coming to talk, this is not what you expected to see. So, yes, im with the Alzheimers Association. Ill say a few words who we are. We are the largest Patient Advocacy organization focused on alzheimers disease. We are focused on two main areas, care and support, were in every state. We provide care and support free of charge. We have 24 7 hot line. Anybody can call any time. We always answer the phone. But we also support research. We have over 5. 3 million americans who have alzheimers disease today. And that numbers growing. We expect that number to triple by the middle of the century if we do not solve this disease soon. Were looking to solve the disease through research. The Alzheimers Association the large largest not for profit in the world. We are the third impactful in the world behind u. S. Government and chinese government, according to thomson reuters. We recognize the need for the whole Research Ecosystem to work effectively, that includes pharma, biotech, government, funders like ourselves. So im going to talk about alzheimers disease, give you back round. A lot of people confuse the terms dementia and alzheimers disease and its important to note that dementia or the symptoms, the cognitive decline, memory loss, there could be multiple causes for those symptoms. Alzheimers is the most common cause but not the only cause. It can be caused by vascular dementia, as examples. But its important when thinking about treatments to understand the cause when a parent comes in with symptoms, its important to understand why they have the symptoms so you can treat them appropriately. What is alzheimers disease . The bottom left picture there is picture of dr. Alzheimers, about 100 years ago. He first discovered this disease. First patient, pictured in the top left hand corner there. She had what we now know is early onset form of alzheimers disease. She had alzheimers in her 50s. When she died, dr. Alzheimers took her brain, looked at her brain under a microscope and saw the hallmark feature of alzheimers disease, plaques and tangles. Plaques we know are filled with am alloyd protein and until recently, that was how alzheimers disease was diagnosed at autopsy. For most people, thats a little too late to be useful. So we now have new techniques that will allow us to diagnose people before they get to autopsy. What are the risk factors around alzheimers disease . Quite a few. But the biggest one is your age. Good news is youve got another birthday, youve lived longer but risk for alzheimers disease just increased. The longer we live, the greater our risk for getting alzheimers were learning about the heart and head connection with alzheimers disease. We flow that theres a greater risk for if you have high blood pressure, Heart Disease, stroke, high cholesterol. We like to say at the alzheimers soesh yas, whats got for your heart is good for your brain. A lot of the strategies about heart health is important, head injury,s that a risk factor for alzheimers and dementia. We know that the apoe4 gene is a risk. It means your risk is higher. I want to mention that if you have got a brain anybody in the room have a brain . I know back here. Thank you. I just wanted to i told that joke regularly, not just dont feel picked on because youre in a room full of politicians. If youve got a brain, you are at risk for alzheimers disease. Thats important. Just remember that. So, as i said, we know a lot more about the risks and there are things you can do to lower your risk. And the same kinds of advice woo ef been giving people about Heart Disease applies to brain health as well. Get out and exercise. Adopt a healthy regiment. Its good for your heart, it good for your brain. You need to get the blood pumping, you need to get things moving. And thats useful for lowering your risk. We also know a healthy diet is important. And also lifelong learning. Dont just get to a certain age and say, ive learned everything i need to learn thats valuable. Keep learning, keep challenging yourself. These strategies may be useful in delaying alzheimers disease but certainly useful in slowing normal cognitive decline that occurs with aging. Keeping your brain healthy, active, moving. Its really important. And we also know theres a lot more we need to learn about these risk factors. And these strategies to kind of combat this. And thats why we need more research. Thats what we advocate for at Alzheimers Association. In addition, our website, ten ways to love your brain. Summarizes the strategy as it someone can take to kind of lower risk factors. Again, its about lowering your slowing cognitive decline as you age and preventing, setting you up for a better chance to prevent alzheimers disease. It doesnt guarantee that youll prevent alzheimers disease. If youre on the path, genetics are against you, you may still get alzheimers disease but this may give you more time with a healthy brain. This chart shows how alzheimers progresses. You dont wake up go to bed one night and completely healthy and wake up one morning and have alzheimers disease. Its a slowly progressive disease that occurs over years. Decades even. And we now know, by studying biology around ageing and alzheimers disease, that the biological changes occur up to ten years before any symptoms occur. So, as i talked about healthy lifestyle, its really middle age when you need to start adopting healthy lifestyles. Its like putting money in the bank for retirement. You need to start thinking about what youre going to face when youre in your 80 and 90s but you need to do it in your 50s and 60s. Dont wait until its too late. Do it now. Even if youre older, we see benefits to those healthy lifestyles. But that can slow your decline. But we flow that the decline in alzheimers disease is precipitous. Its different than normal aging. Its not normal what happens to someone in alzheimers disease. I talked about changes that occur. Here is pictures of living brains people who have living brains that get am alloyd p. E. T. Scan, the pictures at top are the normal brain. At the bottom, yellow and red spot, though are amyloid plaques in a living brain. We have ability to know whos on the path way or who has alzheimers disease. Each one of the leans represent as a biological change. On the far right far left is someone who is completely healthy and then you can see progressively they get sicker and sicker as you move to the right. Lines get higher and higher. But theres a stage where the lines start to grow called preclinical stage. And those people dont have any symptoms. And that stage can last for ten years or more but theyre on the pa pa pathway to alzheimers disease. Traditional lil, drug developers, researchers, worked on the dementia stage, because thats where they could find the patients. They had to wait for the people to have symptoms to treat them. Those people are already really, really sick. And if im trying to prevent a disease treat a disease, id rather have people who were at that stage because your chances are better, your drug is going to work better if you get them earlier. We know from diseases like cancer that Prevention Strategies are far more effective than treating somebody who is pretty far down the road in the disease. And thats what were dreaming of today. A lot of new strategies to treat alzheimers disease are focused on prevention side of the disease. Now that we have these biomarkers we can start to think about that. This is whats approved today, five drugs fda approved. First one, tack rin, first one approved, no longer available. We have four drugs in the u. S. First three are cholinesterase inhib ritter, then donepezil, rivastigmine, these drugs work to treat the symptoms of cognitive decline and work on healthy neurons but as the disease takes over, more and more neurons die, these drugs become less effective until they become ineffective altogether. They dont stop or slow the decline of the disease. In fact, alzheimers disease is the only disease at the top ten causes of death in the u. S. Without a way of slowing, stopping, or curing the disease, the only one. These are drugs we have today. We need better therapies. Attrition rate in Drug Development was discussed earlier. You see the industry average. Amount of drugs that go into preclinical testing with animal models come out with 4 success rate. But, if you look at alzheimers disease, its such a challenge to come up with new drugs, were at. 5 . We really need a lot more shots on goal to have success. We hope, as we learn more about the biologist of the disease, well get better success. Im not going to talk about each one of the drugs in the pop line. But i was asked to talk about the pipe line. As i scientist, what excites me about this list, a list of drugs in phase i, phase ii Clinical Trials, focused on safety, these are drugs looking at attacking the disease from all kinds of different angles. Theyre not just taking one approach. Theres lots of different approaches here which is important scientifically, that will teach us about the disease. Also gives us a better chance of success and hopefully will get more than one approved and then we can go back to whats a combination therapy the way cancers treated. If we do that, that will provide better sushg sccess. Phase iii, fewer compounds, fewer therapeutics. But again, theres a variety of approaches. My last two slides im going to highlight a couple of the candidates to give you a sense where things are. First is from e lli lilly, antiamyloid therapy, injectable if approved, in phase iii. Hope to see data this year at your conference in canada, aaic, big scientific conference, but were hoping to see some data. If approved, it could be the first disease modifying therapy for alzheimers disease. That is, it would slow the decline of people toward alzheimers disease. The other one is a biological, injectable, from the company biog an. They reinvigorated the Community Last year. Why was it exciting . Though it was a small trial of 150 people, every one of the people had amyloid deposits in their brain based on a pet c p. E. T. Scan. After one year, people on active treatment showed slower decline, based on placebo based on the p. E. T. Scan. A first time a trial has been done in this way, knew you were treating people with amyloid deposits in the brain. Were getting diagnostic tools to help guide Clinical Trials. But as i said, we have over 5 million americans and with alzheimers disease today and a prevention strategy is not going to help them. We need something to help them with their symptoms. Two examples, the rvt101 compound, this is another symptomatic approach to alzheimers disease, similar to the approved drugs, but approach to alzheimers disease, but going after a different mechanism of action. And maybe even provide better outcomes. Also, theres a drug from avaner approved for bulbar effect in as and ms. Theyre now under Clinical Trials for alzheimers disease. This causes a lot of problems for people with alzheimers and their caregivers. This is a way to treat a behavioral symptom associated with alzheimers. Attacking from all different angles, really trying to bring new therapies forward. Thats the way were going to attack this disease. We need better support for research and thats whats going to stave off this health care crisis. I want to thank you for your attention. Were happy to work with anybody. [ applause ] now is the time youve been waiting for. Question time. We have a few minutes if anybody has a question theyd like to ask any of our speakers. Yes, maam. I guess my question is the the stages of alzheimers, im going to go into that. And you say its years before its really diagnosed. And so what i dont understand is, the when you say i guess my thought was incorrect, i guess, but that my mom at 94 years old started dementia at what we thought was dementia of some kind at 93 years old. Otherwise, she was fine. And the question i so was that dementia or was that alzheimers and we missed the whole thing . I have no idea. But now seeing my sister going through alzheimers, and really my yeah, my sisters wife going through alzheimers. And just seeing what shes going through at a younger age, at the age of 75, 76 years old, you see the increase daily. There is nothing out there that slows it down then in your feeling . No. The drugs that are approved, they do not stop or slow the progression of the disease. And as i said, its the only disease of the top ten causes of death that theres no way to stop or slow the progression. Is there one type of alzheimers disease or are there other kinds . So theres types of dementias. Alzheimers disease as its defined is the medically is one disease. But as we learn more about the disease, it could be that we learn that there are subtypes. But today, it is defined as one disease. But there are multiple types of dementia. Thats why its important to get a really good medical workup from a top physician to understand if the cause of dementia might be something other than alzheimers disease. For example, there are people who are on the wrong medicines, medications. They have a weird medical combination and so the dementia could be easily reversed. If properly treated. Thats usually rare, but it does happen. So its important to understand what is the what is actually the cause and the course of the disease. We need better not only better treatments, we also need better diagnostics to really get a handle on that, and hopefully identify people earlier in the stage of the disease that these new therapies we hope will prevent their progression. Is it usually the family that notices it more than the individual . Yeah, so its typically a loved one that will report, but often sometimes the loved ones are also reluctant to report it, too. I think we hopefully when we have new therapies well to get to the point where we can tell people how important it is. Under the Affordable Care act, you are now everyone can get a cognitive assessment as part of your wellness visit. Unfortunately, not everybody takes advantage of that. But hopefully as new therapies become available. But its also important to recognize that even without new therapies, its important to know what is going on. Because people especially as they grow older have other health issues. Lets take for example if somebody had diabetes. And they were they were experiencing dementia. If the family kind of brushed that off, oh, its just normal, theyre forgetful from time to time. What happens if they forget to take their diabetic medications . Theyre going to end up in the hospital. Very expensive and unnecessary. But if they had been treated and cared for properly because they actually did have a diagnosis of alzheimers or dementia, maybe that proper care would have prevented a Health Crisis that was not caused specifically by alzheimers disease, but because they didnt have the proper care. So we think that the Alzheimers Association theres great value in knowing your status and your diagnosis. Yes . Mike stack from pennsylvania. Thank you all. We have the one of the lily subsidiaries in philadelphia working on whats the drug . I visited with those folks really unbelievably intelligent and compassionate people. Has there ever been a disease like alzheimers that is this difficult that fits into that paradigm where literally were trying to find out how many people are affected, but its impossible to find out how many people are affected doing it the oldfashioned way, but you know, we always solve the problem, dont we . With great scientists like you. Is there another illness that fits that category so that folks, we always sort of like to build on a foundation . If you look at federal funding for other diseases, you can see where their success has gone. Lets take hiv aids. We remember when that was an unsolvable problem. Nobody had really effectively treated a viral disease. And nobody really knew how to do it. But with the proper level of funding, thats a manageable disease. Its chronic disease, but its manageable. People are not dying at the rates they were in the 80s. I worked in pharma before coming to the Alzheimers Association as a researcher. There was also a joke in the hallway that all the easy diseases had been cured and only the hard ones were left. If you went back 20 years, you would have heard the same thing. Once you solve it, the answers become obvious. We just need better research. And the funding falls in line. When you see success, you often see the money has been invested and the great brains are drawn to that. I notice you had omega 3 up there with different products or drugs to use in dealing with alzheimers. How does that exactly work . I take omega 3 because everybody says take omega 3. I want to be able to say to my wife, ill tell her im fighting alzheimers and she might say its too late. Those are those are potential therapies that are being tested. Theres a hypothesis that omega 3 will be useful for treating alzheimers disease, but we dont know yet. We need to let those to let those trials go forward. The difference with omega 3, its classed as a neutraceutical so you can get it over the counter now. We dont have proof yet. Were waiting for that. Were going to take the time. One more question. Thank you very much. And i appreciate the panels discussion. Ill continue with you mr. Hendrix. You mention the anticipated growth that were going to see people who have alzheimers into the future. Is there some sort of a dollar figure you can put on what thats going to cost us when we get down to the next 30, 40 years and that occurs . Ive seen estimates that one disease, alzheimers disease, will eat up about 1 quarter or more of all medicare spending. One disease. So we believe that if we invested as country 2 billion a year over the next ten years in Alzheimers Disease Research and that yielded a treatment that could delay the onset of the disease by just five years, it would save the country 245 billion over about a fiveyear period. Okay . So that seems like a pretty good investment to me. I was never that good in math. It goes back to the comment before about if we put the funding into it and put the research into it, dont guarantee that youll solve every problem. But history shows that when we when weve worked hard to solve these difficult medical problems, weve made great strides. Thank you. With can i just add okay. Ill use lily as an example because its a great example. Lily over the past 16 years has continually done research on alzheimers and they have brought zero alzheimers drugs to market. If you disincentivize Companies Like lily from doing research on these diseases, then you rub run the risk of the research stopping. The discussion is going in the direction where it scares me. You dont want a company like lily who maybe is on the verge of coming up with something that can treat a disease that will be perhaps a way to solve some of your longterm care costs in your states. We want to be thoughtful how we approach this. Our companies 12 getting venture capitalists, its very, very difficult. You dont want to disincentivize Companies Like this doing research on these types of diseases. We have treatment for a very, very, very small personal of Mental Health disease. There are so many types of Mental Health disease that are being masked with the treatments that are out there. Better treatments are needed. We have a lot of orphan diseases where the money doesnt go into it because its not treating the same types of populations of people, but people with significant, significant illness. There are so many diseases that still need better medicines, better treatments, better hopefully cures at some point where we need to keep the money going into the research. With that, join me in thanking our speakers. Thank you for your time. [ applause ] on the eve of new yorks president ial primary, Donald Trump Holds a Campaign Rally in buffalo new york. Live coverage begins tonight at 7 00 eastern cspan 2. Our live coverage of the special race continues tuesday night. Join us at 9 00 eastern for election results, candidate speeches, and viewer reaction. Taking you on the road to the white house on cspan, cspan radio, and cspan. Org. The National Lieutenant Governors Association recently held their annual meeting looking at ways to advance federal state relations. That included keynote remarks by Michael Botticelli. He spoke about opioid addiction and treatment. This is half an hour. Well, good morning, everyone. If youll go ahead and take your seats i think well go ahead and get started this morning. We do a pretty good job of quieting down. Pretty impressed with this group. We behave. Thats right. I hope everybody had a great evening last night. I thought we had some great panels yesterday. Were going to match that today. Weve got some great breakout sessions. I want to thank you again for being here. I want to thank the caps for their support of nlga. This morning, were going to start with a pretty serious and compelling issue that is impacting children and families all across this nation. Thats infants with drug withdrawal. The National Institute of health, one infant is born into drug withdrawal every 25 minutes. This is an issue that all of us are facing and im excited to have appreciate the fact that Lieutenant Governor sanguinetti is moderating the panel this morning. She not only served on the city council, but also led the local government consolidation on Unfunded Mandates task force. She has a very compelling and inspirational story of her own. I am just really pleased to have her with us at this meeting and to moderating this panel. So thank you very much, Lieutenant Governor. [ applause ] thank you so much for that kind introduction Governor Reynolds. Its great to be here, and welcome to all of you for being here this morning. This morning, we will be tackling epidemic that touches too many lives and also too many of our states. From big cities to small towns to our own Rural Communities. The heroin, Opioid Epidemic is quite frankly one of the hardest, largest, immediate, pressing Public Health issues of our day. From illegal drug use to misuse of Prescription Drug, leaders at the local, state, and federal level are rallying to combat this very problem. This morning, we will hear from the nations drug czar about protecting infants whom are born addicted, about prescriber education, and about expanding Prescription Drug Monitoring Programs and more. So please join me in welcoming the director of National Drug control policy from the white house, mr. Michael botticelli. [ applause ] thank you, governor. Its really a pleasure for me to be here. You might know that the bulk of my career was spent working in State Government in massachusetts. So despite the fact that im a fed now, my heart still lies at the state level because i really do believe that and i want to just start off by thanking the Lieutenant Governor for the introduction to this issue. We have not seen 2014 data show that weve had about 24,000 people die as a result of opioid. That translates to 78 people a day. What weve seen a obviously just kind of no geographic boundaries, no race boundaries, no economic boundaries to this epidemic. Its challenged us because it is hitting parts of the country that havent seen this kind of mortality related to this. Weve also seen a number of other consequences that well talk about today. Not only neonatal, but huge increases in hepatitis c and weve been seeing outbreaking of hiv across the country as is related to needle sharing. I want to talk about a couple things. One, what were doing at the federal level, what we see as state opportunities here. I really do want you know, my colleagues at the federal level i think are incredibly impressed by the leadership of governors and Lieutenant Governors on this issue, state legislatures. Weve seen tremendous amount of movement in terms of of legislation and passage of programs that we believe are important. One of the things that ive been doing this work for the better part of my life. As i think the most essential ingredient to dealing with this issue and quite honestly issues around Substance Use is really about leadership. Thats where i think you come in. I want to thank Lieutenant Governor boyd and others for kind of spearheading state level efforts around this. I want to make sure what were doing at the federal level responds to your needs at the state level. Let me talk a little bit about what were doing at the federal level and what i think are our opportunities at the state level. As the Lieutenant Governor talked about, we can track the beginning of this epidemic to the overprescribing of Prescription Medication in the United States. While the United States represents 5 of the worlds population, we consume over 80 of the prescription pain medication in the United States. Enough in 2013, that we gave every adult american tear their own bottle of prescription pain medication in the United States. Clearly, we want to make sure people who are in pain have appropriate access to Pain Management therapies. Its very clear when you look at the dramatic increases in mortality, they directly correlate to the volume of prescription pain medications that we have. Weve also seen significant variation in state level prescribing. Theres sometimes a threefold difference in terms of state level prescribing behavior. So clearly starting with education becomes really important. Were tremendously pleased that many states have implemented mandatory prescriber education. I do not think its unreasonable that our prescribers however well intended get some level of education as it relates to safe and effective opioid prescribing. Theres a gao report that show that veterinarians get more training on pain prescribing than physicians in the United States. And, you know, we know we have outliar docs and problem docs, but the vast majority of these medications are coming from dentists and primary care physicians. I think you might have seen last week, the centers for Disease Control released prescriber guidelines that we think are very, very prudent. I know a number of states have passed legislation. Massachusetts just passed legislation. A number of states are looking at in terms of limiting the dosage in terms of first time prescribing which we think is important. And also moving the community away from opioid prescribing as a first line defense particularly for chronic pain. Looking at alternative strategies around that. There was a report yesterday that showed meditation is quite effective in dealing with lower back pain. We also have to retrain our consumers away from thinking theyre Getting Better health care when they get a pill. We talked about Prescription Drug Monitoring Programs. When we started, we only had 20 states that had Prescription Drug Monitoring Programs. We have 49 states now that have prescription Monitoring Programs. We continue to focus not just on looking at a number of key areas as it relates to one, interstate operability. Making sure they can talk across state lines, so were not pushing consumers from one state to another. Also working on opportunities to increase the utilization of those by integrating those with Electronic Health records. We want to make sure these are good programs to be able to do that. Weve also been continuing to support grants to states to support a wide variety of activities. Just last week, secretary burwell announced 100 million in new funding to integrate treatment into particularly our Community Health centers. We know that many parts of our country, rural parts, that dont have treatment programs need access to care. So weve been focusing on how do we get some of these grants into communities that dont have bricks and mortgagor treatment programs. I would encourage all of you to make sure youre optimizing were going to be having more grant calls coming out next week. So making sure youre taking opportunities for grants. Just last month, president obama and part of his fy 17 budget announced 1. 1 billion for fy 17 proposed funding to close and support the treatment gap that we have here. The vast majority of that money would support twoyear cooperative agreements with states to support expanded treatment capacity. Despite, you know, our advances with the Affordable Care act and medicaid, we know theres a big gap between how many people need treatment and how many people get it. In my job, i cant ask you to advocate for things, but i would thoroughly encan you rememboura communicate your state needs. Quite honestly, we need funding for this issue now. You know, last Year Congress appropriated over 1 billion for ebola and we had one person in the United States die of ebola and we have 78 people dying every single day of drug overdoses. We know despite support from congress over the past few years that we have too many people who still need treatment in the United States who are not able to get it. These are people who end up in, you know, our criminal Justice System. These are people who end up in our Child Welfare systems. These are people who end up in our emergency departments. And these are people who end up dying. And we need to make sure that were doing that. Clearly, it requires partnership. And weve seen, i think, some significant opportunities. And then ill end and talk about neonatal syndrome. Were beginning to see an emerging picture of what are the things that we need to do at both the federal and state level. We september out a letter to governors last week as a followup to the nlga meeting that we had. What are statebased best practices that we think are important as part of your overall state plans to be able to do that. Were starting with prescriber education. We have i think 14 states that have passed mandatory prescriber education. Weve gotten commitments from many of the Major Medical organizations to enhance their training on it. So we think that thats an important priority. You know, obviously continue to support and fund Prescription Drug Monitoring Programs. Weve seen some really good results in states that have really good Prescription Drug Monitoring Programs that also require prescribers to check them. Weve seen in states like new york, tennessee, and florida dramatic reductions in both overdoses and doctor Shopping Behavior by where we have really good programs to do that. So clearly, you know, more timely data Prescription Drug Monitoring Programs and requiring prescribers to check it. One of the things weve seen, i think we have 33 states now that have some level of legislation that allow for sterile syringe access program. Weve seen significant increases in Viral Hepatitis associated with sharing needles. Many of you might have seen what happened last summer in scott county in indiana. Very small county. 9,000 people because of needle sharing behavior with Prescription Drugs, they had over 180 new cases of hiv. The governor there actually passed legislation to allow for a syringe access program. So i encourage you to look at that. Weve all seen remarkable results around melaxone. Really tremendous and kind of safe drug that reduces overdoses. Weve been looking at a number of ways to do that. Making sure that every First Responder is carrying it. But also family and friends to be able to do that. And weve also seen states that have been passing legislation to allow for over the counter access to melaxone. We have 35 states now that have passed some legislation to look at thirdparty prescribing and pharmacy access. I know we have some of our partners here from the pharmacy chains and i want to thank them for the work that theyre doing. You know, one of the things that weve seen i think has been great is particularly Law Enforcement and Public Health working hand in hand. I think weve all come to an understanding that we cant continue to criminalize addiction, arrest and incarcerate people with that. Weve seen great partnerships between Law Enforcement and Public Health to be able to do that. With a police chief in dayton, ohio, where theyre identifying people who have had an overdose and working with them to get them into treatment. In massachusetts and around the country, Law Enforcement officers are working to quite honestly case manage people into Addiction Treatment. So let me just talk for a minute about neonatal. Its one of the issues weve been hearing a lot. The Lieutenant Governor talked about the magnitude of pregnant women with addiction. I think there are a number of ways that we need to respond to this issue. And one, i think is looking at making sure were having a compassionate response to pregnant women with addiction. I think that weve seen quite honestly as legislation that puts enhanced criminal penalties on pregnant women with opiate addiction. That really discourages women from seeking care. It ends up costing our medicaid systems for women who are afraid to access care because of increased criminal penalty. We have to make sure were doing everything we can to encourage women to get good prenatal care, to make sure theyre getting treatment. To look at not only getting good treatment, but we also need pregnant women and postpartum women need access to a wide variety of services posttreatment. We continue to ensure at the federal level were providing states access to longterm residential care. We are very, very happy that actually Congress Passed and the president signed the protecting our infants act. Part of what that does is making sure that we have good treatment protocols in place for dealing with pregnant women. And the last thing that ill say, and particularly i saw this in massachusetts as a state person, that we really need good solid collaboration between our Child Welfare agencies and our substance agencies. Thats particularly important to look at how these two systems communicate. And ensuring while were simultaneously protecting the welfare of children that were working collaboratively to deal with the addiction issues in pregnant women. To make sure that we have a coordinated response to this. I was just in connecticut where the governor there announced what i thought was a really interesting project using social impact bonds to focus on reducing costs and reducing the magnitude of addiction on the Child Welfare system. If you havent seen it, we have representatives here, and the Lieutenant Governor from connecticut who could share that with you. I think it was the first time weve seen the use of social impact bonds focusing on Substance Use issues and how we can Leverage Private equity to be able to deal with that. Let me end by saying i think you all know this is an important priority for president obama. Last october, he went to West Virginia where we held a town hall forum. The president is going next week to atlanta to the national Prescription Drug abuse and heroin summit run by chairman rogers just to demonstrate that this is a president ial priority, that we need all hands on deck. You know, we are working on a you know, all of government federal response to this. So with health and Human Services, department of justice. But we also need and ols recognize that we need strong partnerships at the federal, state, and local level. That we need all hands on deck to make sure that were dealing with this issue. So im really pleased to be here today. Want to thank you for all of your leadership, your continued focus on this issue. And making sure that we have continuous dialogue with both states and the federal government to make sure that our policies and resources are attuned to the issues that youre facing at the state level. So i want to thank you all for the work that you do and happy to answer questions or hear comments. Thank you, everybody. [ applause ] thank you so much for your insight, director. This is our favorite part. This is where the floor is open and you folks get to pepper the director with questions. So, first question. Thank you, governor. Thank you, mr. Director. When you open up and talk about leadership. Our son had seen you at a medical school, ama grouping. And you inspired them to understand that when a script is written, you dont need to have a 30day script for a lot of these. For your outreach, talk about leadership and inspiring those people. Its pretty impactful. So thank you for being here and encouraging us. As we were talking to you coming in, im background in emergency medicine as a nurse. There was a story that i was told by a friend of mine whos a psychologist that works in our diversion programs that an individual who has a severe monkey on his back has a friend that over the last year and a half continues to drive over his hand so that he can continue to get access. So hes had his hand driven over three times. One of the points that he brought up to me in a lunch that we had in a small town where i met him is that with all of these monkeys that people have in these demons, that we dont have very good crosscommunication electron electronically, not only in terms of electronic prescribing, but there isnt one testimony for telehealth delivery. We have so many credentialling issues. The same in the v. A. And in these Community Health centers. One of those pieces is to be able to integrate. I hope that with our Community Health centers and federally qualified centers and whatever that there could be leadership from you and the administration to streamline this process so that we can have, regardless of the size of the cities, the communities, telehealth, Behavioral Health support for treatment whether its in a prison setting or Community Corrections and diversion. Because this hodgepodge is what i actually think is a huge systems failure that we could fix. Other than that, i dont have any opinions. Thank you. You know, one of the issues that i think this epidemic has really brought to light is that for a very long time weve had firewalls in many respects between medical care and Substance Use issues. You know, and so part of our kind of overall work is to look at how do we integrate around primary care, particularly in primary care settings. I know that we have a long way to go to do that. One of the issues that we have heard that were trying to deal with is to look at Confidentiality Laws as it relates to sharing information with particularly within Health Systems and Electronic Health records. Clearly, we want to make sure we still have some level of protections, but we dont want to inadvertently create these systems that cant communicate with one another or share information as it relates to that. So hhs has proposed modifications to the confidentiality law that would help facilitate better communication between and within Health Systems for people who are receiving both primary medical care and Behavioral Health care to do that. I know that doesnt solve the entirety of the problem, but were really trying to look at ways in terms of better sharing of information and better integrated care within primary care settings and within larger medical settings. Great question on streamlining the process, which brings followup to the next question. Director, thank you. Excellent presentation. Mike stack, pennsylvania. I thought that was a really interesting point about veterinarians having more training for prescription training than actual physicians. I think that really goes to the point that we do not do enough training on addiction in general. Medical students have no idea what theyre looking at. And i think theres a lot of different ways to approach that, whether we mandate that medical schools have larger blocks of training, thats one area. But the key is, i think, what youre talking about. In this country, were all finally starting to get over the stigma of addiction which is one of the things that gives it so much power, and were trying to maneuver our way through this to save lives. And at the end of the day, too, you know, treating addiction is one of those areas gets way in the back of the line for funding, whether its a state level or federal level. And what youre trying to do and were trying to do i think is push it forward. Because its one of those cases where you can spend the money now on treatment or we can continue this process of spending billions on corrections and Law Enforcement and all those things. So i really appreciate the point youre making and i would just look forward to working with you and other Lieutenant Governors on prioritizing treatment and, you know, another issue too that youre talking about that were maneuvering our way through is just the whole confidentiality issue. All these things are really important. For me, that was an important point on the issue of pregnant moms trying to seek treatment. I think most people react to that emotionally. And angrily instead of seeing it for what it is. Its a heartbreaking aspect of the need to get folks treatment. So typical Lieutenant Governor, no real question. Just wanted to make a big speech. Thank you. And i mean this sincerely. You, governor wolf, secretary tennis who i know very, very well from pennsylvania are really doing outstanding work in terms of looking at this issue. And a couple things i think are important that you talked about. One, kind of the role that stigma plays in preventing people from getting care. Substance use roughly has the same prevalence as diabetes yet the treatment rate for diabetes is 80 to 85 . In the United States, only about 20 of people with addiction are getting the care and treatment that they need. To your point, that is not a free pass. You know, we know that that has resulted in an inordinate effect on your e our medical system, certainly on our criminal Justice System when you look at the percentage of people in our jails and prisons as a result of it. I always say that funding Addiction Treatment is one of the best returns on investment that you can make sure. Sure. And you know, again, i think we have a really great opportunity. And particularly looking at what, you know obviously states have a tremendous amount of flexibility in terms of what their medicaid benefit package looks like, particularly with generous fpp, for medicaid, looking at your medicaid package becomes instrumental in doing that. Ultimately, when we invest in that, were really saving money. We see the biggest cost offsets on the criminal justice settings. I know that many of you are struggling at looking at ways to diminish the jail population that we have. Thats often kind of one of your greatest expenses at the state level. To be able to do that by really moving people away from incarceration. Weve seen, you know, just remarkable results in terms of of when you, you know, implement good Addiction Treatment programs, when you implement things like drug courts, they have a tremendous savings opportunity as well quite honestly as a much more compassionate and humane response to people. The last thing ill say is, when you look at data, stigma still plays a huge role. So anything that you can do i think to call attention to this issue, you know, as ive talked to a lot of people in this room, you know, i havent met a family that hasnt been impacted by addiction. And i think the more that you as leaders can talk about that or feel comfortable with that or hold up people in recovery in your state, you know, we need to make sure that were diminishing the stigma associated with this. Ill tell you just one last thing, too. Gary mentioned, hes in pennsylvania we have a secretary of drug and alcohol. When we started that, a number of legislators were sort of like, this is more government, its an extra cabinet position. But its really worked out well and hes been a leader on the issue. I can tell you my own experience as a state senator, we spent a lot of time with constituents and their Family Members finding ways to connect to funding to get them into rehabs. If youre representing people, most likely youre going to represent people in crisis who are trying to get help for their loved ones. Big part of it. Thank you very much. Next person with either a kwurry or a thought. Maam . Kathy hochul, new york state. I also Wish Congress would step up and do right by the American People and put the fund sthooeshlg for this. I have a little bit of a history as a much crack cocaine was the crisis of the day. And i recall working on a 1. 4 billion bill back then. In todays dollars, i have no idea what that would be. But i think we can do a lot more to help provide monies for state targeted treatment and rehabilitation progra. Also, access to the Prescription Drugs comes in many ways. We had a prosecution that one doctor on vacation was found guilty of prescribing 19,000 scripts for Prescription Drugs. Our Governor Cuomo just this past week directed that all prescriptions occur electronically. We need to have some time to get that in place. But i think thats a way you can stop people from literally selling the scripts and creating access there. Is there a central repository for the best practices of states . We are coming there are a lot of great ideas. Im hearing some today that i want to make sure were doing. We feel were leading, but theres other ideas out there as well. If thats something that your office is providing already and we need access to it. We all need to be in this together. Its a state, federal, and local issue. Were desperate. We are losing people. In my county, were losing one person a day for two weeks straight. Ill also say that the the numbers are underrepresented. Because we had over 200 deaths in one county, but 900 in narcam saves. Thats the crisis level were at. So we actually i think we were going to try to do it for this meeting. Well get you the letter that we sent out governors that listed kind of basically 11 best practices that weve seen that are coming out of the states to do that. I know that many of you are already working on those kinds of issues, so wed be happy to share that with you. The other thing ill say that i think new york state did that was really important was to look at the enforcement of parity protections for people with Mental Health and Substance Use disorders. One of the things weve seen with private insurance, a reluctance to treat Mental Health and Substance Use disorders the same way they do other medical disorders. With the Affordable Care act also was the medical Health Parity and addiction equity act that requires insurers to make sure they were administering those benefits at the same level. Weve all heard widespread reports of people feeling like theyre not getting their full due as it relates to parity. I think new york state, working with your insurance commissioner, i think did really great job at looking at enforcement issues for private insurance. We need private insurance at the table as well. Wonderful. Next query. Thank you very much. Thank you very much for being here. Im nancy wyman from connecticut. I guess something that you touched on. The fact as the governor from new york had said, prescriptions. I guess the prescriptions in most ways are written by doctors. And how do we change the medical field to try other things besides just writing that prescription or at least monitoring the amount of the drug that they give somebody. You know, i think with the release dr. Frank is here from health and Human Services. Hell probably spend more time talking about this. But the cdc just released their guidelines last week that are really focused on chronic pain, but they also talk about treatment for acute pain. I think there are a number of things to look at. Some of this relates to farther back, how do we integrate issues around addiction in medical school because i think that becomes really important to do. But again, i think, you know, where looking at some level of mandatory education, prescriber training i think becomes really important to do that. Checking Prescription Drug Monitoring Programs becomes really important. There are some states that require prescribers to check the Prescription Drug Monitoring Program at least at the initial prescription and then, you know, subsequently thereafter i think becomes really important to do that. So, you know, i think to look at the cdc guidelines and how you work with states looking at how might we integrate those cdc guidelines into the Medicaid Program to be able to do that i think becomes really important. So because i do you know, i do think that the vast majority of physicians are and dentists, dentists are pretty high prescribers of prescription pain medication as well. You know, i think the vast majority of people are well intended. I think they were misinformed by the addictive property of these drugs. Were lobbied very heavily by pharmaceutical companies to continue to prescribe. Again, we want to look at also nonopioid therapies for it. So it will be interesting to look at medicaid plans and to what extent they support nonopioid prescribing Pain Management strategies. So things like physical therapy, making sure that Cognitive Behavioral Therapy is important. Can we look at not only just nonincentivizing opioid prescribing, but incentivize other Pain Management therapies i think becomes really important. Great point. I just want to follow up on that. If you could give another example of a state that has actually done that with the cdc and their Medicaid Program, i think that would be helpful. If you can get the information to julia, then she will have a central repository and post the information on our website so we can access that at any time. I would not diskurnl you from sending it to individual governors. Happy to do that. I wondered if you could speak a little bit about the impact to the foster care system. It speaks to the collaboration and not operating in silos and how we have to deal with this not only federal and state, but the community levels. To continue to look at it from a holistic perspective. Youre right. So, you know, i can tell you my experience in massachusetts. We know that a significant and escalating with the opioid issue that weve seen increased referrals to the Child Welfare system as a result of the opioid addiction. These are two systems that in some respects need to work Better Together to ensure that, quite honestly, Child Welfare workers have some level of education in addiction. That they have established partnerships with treatment programs that can treat pregnant women and women with children. That you have Substance Use services that actually support women and children accessing care. So, you know, i can tell you sometimes women have to go through this like sophies choice thing about do i go to treatment and then what happens with my children. And so supporting i think reh rehabilitation programs that do familybased treatment become really important. And again, the federal government, you know, puts out grants to support pregnant and parenting women. I would encourage you there is actually a Technical Assistance center funded through our Substance Abuse Mental Health and services administration. Well get julia information as well. Its called the National Center for Substance Abuse and Child Welfare. It provides Technical Assistance to states to look at good protocols, good treatment with Child Welfare agencies. Its a really good asset. Wonderful. Next well, were getting ready to wrap it up, so im going to take the last question. We got one from vermont. Thank you very much. Phil scott from vermont. First a comment, thinking about our experience in vermont, or maybe a plea. We have a number of communities who have just as Governor Reynolds talked about, brought together community leaders, state resources and local Law Enforcement and so forth. And theyre having some success in doing so. My plea is to, if there is money that comes along, when it comes along, that it remains as flexible as possible. Because one size does not fit all. We found some success in this community, that would be beneficial. The other question i have is maybe a hotter topic in vermont right at the very moment, were considering legislation to legalize marijuana. And im wondering if you have an opinion as to whether that has leave that for the last question, will ya . With that in mind as drug czar, does this have any relationship at all with the opiate discussion . I actually point to the assessment that the Vermont Department of Public Health did. I think it was a thoughtful report that they did. I actually point other states. I do have a lot of strong feelings. So, one ill separate it from the opioid addiction first. I really and im a longtime Public Health person, so this is not coming from a idealogic perspective. We made a lot of progress in the adolescent youth rates. We have at the highest level that weve seen for youth in history. One of the things we track is perception of risk because we know if you perceive something as risky, youre less likely. We have the lowest levels among youth in this country. We have more 12th graders smoking marijuana than we do tobacco. Quite honestly, governor, part of what weve seen is the development of this billiondollar industry. Its not just legalization of marijuana, its the commercialization of marijuana. So, you know, weve seen just billions of dollars being poured into this Marijuana Industry that quite honestly looks remarkably similar to the tobacco industry. And, you know, and i i i understand that we dont want to have people arrested and incarcerated, have long sentences as a results to particularly simple marijuana possession. But i dont think legalization is the way to do it. I think its bad Public Health policy and i think were going to pay the price for it. The other thing ill say, its pretty clear all of you have probably had listening sessions when you talk to people struggling with opiate addiction. And you hear from people time and time again that they started at a very young age and they often started with alcohol, tobacco and or marijuana. Its that early use that sets the trajectory for addiction. I i do have some concern that while everybody has been focused on what to do on the opiate addiction side that were moving in the opposite direction as it relates to marijuana. The last thing ill say, though, what were trying to do on the medical side is really enhance good Scientific Research on the potential therapeutic value of medical marijuana. I think thats really important. There appears you know, that we want to make sure that we are investigating not just the health harms of marijuana, but what might be the potential therapeutic value. I do think that there is continuing evidence to support that there might be some therapeutic value for a whole host of conditions. I want to separate the two issues because, you know, we do want to encourage and were trying to do everything we can to diminish some of the barriers that the federal government had in place on supporting Good Research for medical marijuana. Thank you for all of your thoughts, your questions. Director, thank you so much for your thoughtful insight and your time today. I know we really enjoyed peppering you with questions. So i move onto our next speaker. [ applause ] on the eve of new yorks president ial primary. Donald trump holds a Campaign Rally in buffalo, new york. Live coverage begins tonight at 7 00 eastern on cspan two. Join us at 9 00 eastern for election results, candidate speeches and viewer reaction. Taking you on the road to the white house on cspan, cspan radio and cspan. Org. The National Lieutenant Governors Association recently met to find ways to advance federal state relations. That looked at federal and state efforts to combat opioid addiction. Richard frank was the speaker. This is about an hour. [ applause ] well, thank you. It is good to be here and its good to go to a conference thats just a couple miles down the road. Thats always convenient. Although, dealing with d. C. Traffic is not always the best thing. But i want to thank director botticelli, a number of things that he talked about, in particular responses to some of the questions and queries that came in are things that we addressed in maryland and continue to address. And this is really a worthwhile subject. I want to ask, though, to come to the stage mark bosen and secretary frank, if they can make their way to the stage. You know, the previous conversation and discussion is good jumping off point as we get more specific in terms of tackling the opioid abuse issues in the states. The department of health and Human Services is executing a multipronged fight for the dealing with the opiate epidemic. Id like to have us welcome from hhs assistant secretary richard frank. [ applause ] im very pleased to be here. And usually Michael Botticelli and i do this as a pair. Im not used to following him. But what id like to do is really focus in on what hhs is doing. And im going to sort of in a sense do this in three parts, which is first id like to briefly review what the hhs strategy is and put it a little bit in context. Then give you brief progress wh. And then i want to spend a couple of minutes about where were going and thats a focus on this years president ial Budget Proposal and happy to take questions. Left week, you all know, cdc released prescribing guidelines and hhs released its National Pain strategy. Believe it or not, thats not a coincidence. In fact, we view the two of them marching in lock step together. We have a pain problem and an opioid problem, theyre interconnected and can only be dealt with together. The prescribing guidelines are really aimed at addressing one piece of the pain problem which is when we use opioids to deal with pain, how do we do that in the safest possible way. The pain strategy outlines beyond that a program of research, provider education, patient education, and continued sort of Programmatic Development so that we do a better job on Pain Management in this country and do it safely. All of this is in embedded in the secretary and president s approach to corralling Opioid Epidemic. What id like to do, first, quickly remain you of what strategy is. Theres three prongs. Literally, week that Sylvia Burwell arrived at hhs she convened a meeting she directed us tos develop and evidencebased focused plan to deal with the opioid attempt. As you probably, many have seen the secretary in action, she wanted it quick. Shes all about execution. And believe it or not, we got it to her quick. So theres three parts to it. First part focuses on dealing with opioid prescribing practices. And that involves a combination of doing things to improve clinical decision making, such as guidelines provider education but Decision Supports, like using our Health Information technologies and Prescription Drug Monitoring Programs so that we support doctors in making the best possible decisions. Then we also want to make the data flow more easily and more freely so that in fact a doctor can see, a patients entire treatment history and all of the places theyre touching, the medical system, whats happening there so you dont get the situation that was recently pointed out where 70 of the people who recently overdosed from a prescription pain medications get a new prescription for pain medication. Thats not happening because doctors are doing a bad job. Its happening they dont see the whole picture. So this is very important. Second part is about na lox own. We have a drug that reverses overdoses. What we are really focused on is two things. One, getting it to the right hands at the right time, and that involves sort of tweaking science so we get more userfriendly versions on the street and into the right hadnts. In fact, overdoses dont necessarily happen near an emergency room or near a welltrained First Responder. Very often its the police, Family Member or somebody else on the playground who is the First Responder. And having a user friendly way, administering the drug, is very important. So weve been sort of pushing the development of that as well as making it financially possible for communities in high need to deal with it third piece of the puzzle, medicaid assisted treatment. We have a package of strongly supported evidencebased treatments for dealing with opioid use disorder and those medication assisted treatments that involve three drugs. What we are really bent on doing is making sure that we expand access to those treatments and really fill that treatment gap. Right now theres about 2. 2 Million People in the country who have an opioid use disorder. A little under 1 million get treatment. And we believe that, you know, some people dont believe they need treatment, those are very hard to get, but a lot of people dont get it because its not availab available, they cant afford it, theyre not fully sure what to do about their addiction and its those people, we believe, that we can get all of them into treatment by making the right inhai inhai investme investments. Let me turn to progress weve made in each of the areas. Cdc guidelines came out last week with the pain strategies and thats an important, first step. Were coupling that, ill tell you more about in a minute, wit money to make sure we educate physician communities, support the Surgeon General in his efforts to educate doctors and other providers and get the word out and then make it part of our electronic Decision Support systems. Second is, in september, we released a variety of funds to help cdc expand the use of Prescription Drug Monitoring Programs across the country. The cdc put out an announcement where we are going to go from 16 to about 28 states and then hopefully by the end of the year, to 50 states where we really invest in Prescription Drug monitoring it programs. The president put out a president ial memorandum in october where he insisted that all federal departments take measures to do several things, first, to train all of our physicians in appropriate prescribing. And literally every month we meet and monitor. We have a dashboard and, for example, hhs is now up at 93 , d. O. D. Moving ahead quickly, v. A. Has been accelerating over the last few months. So were pushing all of our own doctors because in fact we have to get our own house if order if we ask everybody else to. The president also directed us to review all of our programs to see where it is that were posing impediments to things like medication assisted treatment and to work on clearing those away. Third, at the president ial event in West Virginia, the administration announced that 40 provider groups have voluntarily agreed to up their games in terms of training members in appropriate prescribing. And we meet monthly with those groups and were getting great responses, everybodys committing to numbers, metrics, and were moving ahead with that let me turn to the budget. Youve heard about the hhs portion of it is 1. 1 billion of new money and the lions share of that money, about 9. About 960 million is going to expand treatment opportunities to close that treatment gap that i mentioned earlier. As i said, we believe that we know what to do. We have the treatment. We understand where the holes are in the system, both geographically and sort of institutionally. So, in many respects, getting the people who are interested in getting treatment and cant get it or doing our outreach work to persuade those who are persuadable, we think we now how to do it and its really about the money. In addition, were putting 10 million of new funding, expanding guide leans and developing support tools base the on those that can be used in physician communities. This is on top of the new investments were making in Prescription Drug Monitoring Programs for 77 million. Finally, we are targeting high need, low resource, Rural Communities to naloxone, weve approved a user version of naloxone thats internasal, so lay people can administer it. Know how long to do it, having as many Health Professionals how to administer naloxone in the safest possible way is key. Were putting 10 million and targeting communities of high need, low resources. So, in wrapping up, were tracking these trends carefully. We have active monitoring and research program, we track our progress, we track everybody elses progress, we meet monthly. It starts at the white house. Michael and i see each other a lot. Were sort of focused on those three targeted things. That done mean that were not doing a variety of other things and michael touched on i a few of those in his remark. We think the evidence points us to making the big difference, having the highest impact by focusing on the proof prescribing, expanded use of naloxown and making investmented in medicationassisted treatment. When it comes to states, literally, we touch you guys in different ways every day and youll notice, if you look into the details of the budget, that the medicationassisted treatment, their grant programs, cooperative agreements, and really meant to be partnerships. We want we recognize that one size does not fit all. We recognize that circumstances and values differ dramatically across the country. Its a big country. Most importantly, we also recognize that weve learned things from the science from our experience so that in fact, there are things that we know work and there are some things that we know dont work. So we view our partnership as sort of offering general guidance on what the evidencebased Playing Field looks like and then we just view ourselves as wanting to partner with you all to make headway. Stunningly, i think, this is one of those areas where there isnt a huge amount of difference in the ideas. I think the idea are shared ed bipartisan, shared by states and federal government. Some of the execution things differ, but thats natural. What really is the sort of keys to the kingdom here is putting the money, right amount of money in the right places. Ill stop there. [ applause ] thank you, mr. Secretary. Well hold questions until we get to the end of the panel. Next, id like to bring up a gentleman will talk about the pharmaceutical industries efforts and new formations as well as more information medically assisted treatment. Please welcome pharmacist and attorney, mark boesen. [ applause ] thank you. Tremendous honor to be here this morning. Again, my name is mark boesen. In way of disclosure, i work for a company, manufacturer of a medication called vivitrol, the extended released portion of i wanted to disclose that bias that i will bring to the presentation. Im not here to talk exclusively about vivitrol but specifically medicationassisted treatment. My background is pharmacist and attorney, mostly pharmacist. I began my career early on working for the Main Association of Substance Abuse programs. It was during a time when it was the early 90s when we only had one fdaapproved medication to treat opioid addiction, that was methadone. Buprenorphine was approved and used more widely in 2000. In 2006, fda approved extended release nal trex own to treat alcoholism. Four years later, approved nal trex own to prevent relapse of opioid addiction. Let me start with the history of Substance Abuse treatment. One of the challenges were fighting today is that evidencebased Substance Abuse treatment is not very old. American society of addiction medicine pubbilished placement criteria in 2012. I like the an al they use in the forward, talk about the evolution of Substance Abuse treatment and United States is using a cycling reference. I thought, gosh, i got to see how they work that in. They talk about at the beginning of this past century and for many decades until modern times prevalent Substance Abuse treatment modality was 12step programs. 12step programs are effective for thousands, perhaps millions of people. But asam referred to it as unicycle approach. Some people can learn how to do a unicycle and some can do it very well but its very difficult and a number of people who will never, despite how much training, will never be proficient riding a unicycle. They hout weve got to have Something Else for people who cant get to recovery with 12step programs alone. So they added Recovery Support programs. Recognizing that Substance Abuse treatment isnt just 12step programs, isnt just counseling but affects so much of your life we needed Recovery Support programs behind it. Talk about the tlhreelegged stool, education, jobs, housing. And asam referred to that 12step programs with psycho social support along with lifestyle manage mement, educat, housing, that was the bicycle. A bicycle is easier to ride than a unicycle, but we still hat people falling over. People suffering with this disease. Wasnt until we recognize this was a brain disorder. In some it was a brain disorder we have no cure for. A lifetime affliction the asam describes tricycle as that component that takes all of the interv interventions we discovered have been successful, psycho social support, Recovery Support services, and medication assisted treatment. We talk about director botticelli talked about people being treated with diabetes. 80 of those are receiving adequate treatment yet a small percentage of people with Substance Abuse disorders get adequate treatment, treatment at all. Implementing medicationassisted treatment is the current stateoftheart evidencebased approach to giving people the best chance of recovery and recognizing that without evidencebased medicine were not going to get very far and were not going to have much impact on this program what can the states do . What are the states doing . There are two things the states can be doing. One is making sure that payment models provide equal access to all evidencebased medicine. Director botticelli described the best return on your investment is investing in Substance Abuse treatment, particularly medication assisted treatment and making sure patients, no one size fits all, make sure patients have access to all fdaapproved medications. In particularly when it comes to looking at some of the issues that are going on, there are two things that lied like to highlight in the states. One started in maryland. Washington county, maryland, the first county in the United States that decided to use extended release nal trex otrex prisoner release. Understanding inkartzrati incars roots in substance disorder. Using extended release naltrexone, once a month, lasts for 30 days, injectable medication, patients have a blockade on let me back up a little bit. I promised to talk about all three medications and how they work. Start with methadone, the oldest medication. Methadone is an opium, its in the same class as morphine, oxycodone, other longacting pain medications. Its very effective because it is a longacting opiate medication itself. When used under appropriate medical supervision, people are able to satiate their cravings because theyre getting opium replacement therapy and getting it in a controlled environment and many patients tend to do well on methadone placement therapy. They take it every day, they report to, and they have to report to, a licensed Methadone Treatment Center to get the care. One of the deficits, it has to be done in a methadone treatment facility. Next iteration is another opium medication, partialing agonist satiates the craving, allows people to function and one of its benefits it can be used in a primary care setting with credentialling of the prescriber. One of its deficits is prescribers need to get special training for it. They need to obtain a waiver thats not a difficult process when you have appropriate training. But the number of patiented that a primary care doctor can see is limited to 100 per doctor. V vivitrol sits on the opium receptor, and it lasts for 30 days. When givenen as injectable form. Doesnt require special training. Anyone with any prescribing credential, whether it be a al low pathic, osteopathic physician, can prescribe the medication. Its highly underutilized, in my opinion, its fairly new, and its an injectable. People when given a choice would rather have oral medication versus injectable medication and theres education that goes with it. Also an education gap. There are a number of primary care doctors, even addiction medicine specialists unfamiliar with the newer therapy. I like to tell the story how when i was hired, my wife is a nurse, she said what do they do . I said make a once a month injectable, treats alcoholism and prevents opioid addiction. See said theres one of those drugs . Why arent more people on those drugs . I said, i know, were working on. What are states doing with therapies . Particularly with the newest one, extended release naltrexone. I started to talk about it, ill go back to. Washington county, maryland program. Recognizing there was a revol revolving door of people arrested and incarcerated as a result of Substance Abuse addiction disorders we wanted to figure out a way to get people into recovery in a way that didnt involve a controlled substance, because, frankly, some of the criminal behavior had to do with usage, possession and diversion of controlled substances and providing them with another controlled substance maybe wasnt the preferred mechanism that we wanted to go to. And utilizing the extended release naltrexone which United States a blocker, nondivertable, nonnarcotic, flan addinonaddicte for 30 days, combining that with social support, counties Like Washington county, maryland, serve years ago ran a successful prisoner reentry program. People would get a shot before released, and then Community Support providers would provide wrap around services, provide more injections upon release, and the fda studies that studied vivitrol said six months is a good period of time to reevaluate the person to see if they still need the medication, i not life long medication, someone with right support and treatment can be in longterm recovery without the medication. Today there are over 100 programs progra programs in 30 different states. The other application is being utilized in foster care program. I come from arizona. The governor approached us and said 80 of the children that we remove from the home are not removed because of abuse, theyre removed because neglect. 80 of the neglect can be attributed to some sort of Substance Abuse disorder. I would like to be more aggressive. Implement a program where were treating the parents of these kids so we can send them back home. That is a program that is its earliest stages, one that has tremendous theoretical process and arizonas studying implementation there. I will end my remarks, because i have yellow light. Im pleased to be here. Pleased to answer questions you might have at the end. Thank you very much. Im going to speak about what weve been doing in maryland over the last year, which is occupy a good portion of my time as governor asked me to head the heroin and opium Emergency Task force. It really started a little more than a year ago, almost two years ago, we were campaigning and traveling around the state and talk to thousands of individuals and mostly talking to local officials, all of you have done that process and go through and talk to local officials and say, what are the biggest issues youre confronting, and we were hearing over and over again that it was heroin. It didnt matter if we were in large communities, large, urban areas, or suburban or small rural towns. We were hearing heroin. And the governor decided, you know, once we were aelected we were going to do something about it and get very much involved in trying to address this particular issue. In fact, the governor lost a cousin to heroin just a few years ago. So he had a personal interest in it as well. We heard of the devastation to families and how it had overrun local and state efforts and had created essentially a Public Health issue, a family crisis, as well as Law Enforcement issue. And so, you know, we set out to once elected, we set out to put together this task force. We brought together experts in medicine, Substance Abuse, treatment, Law Enforcement. We held meetings which we called regional summits around the state. We produced report in december of this past year with 33 recommendations to the governor on actions that we can take to try to address this issue. Prior to the final report, we put out an interim report back in the summer which had ten steps that we could take immediately because we felt that we didnt want to just wait until the end of the year with report if there were some things we could take through our state agencies. And most of that had to do with treatment because we had access to funding in the year and we could expand Vivitrol Program that was just mentioned that we knew about that was going on at local level as well as additional education and prevention efforts. So, the recommendations, final recommendations, dealt a lot with improving Public Awareness and prevention, access to treatment, quality of care, alternatives to incarceration for nonviolent offenders who had Substance Use disorders as well as better Law Enforcement coordination. As governor michels talked about one of the things that we also recommended was integrating our systems a lot better. Our information systems. One of the im going to say it one of the stars in our cabinet is our secretary of human resources, which heads up all of the social Service Agencies and he doesnt come from a Public Health or Public Service area. He comes from information technology. And so one of the things he noted right away was, the state touches a number of people in different places in state, but we dont know, were not coordinated. Come in with social services, Child Welfare, we dont know they also have been touched by our criminal Justice System or dont know theyve been touched by our public housing. And so weve talked about and the help aspects as well. We are trying to put together bring together a lot of the information with the understanding and the privacies a concern and its also, you know it as well as i do, you can have one system, j. Smith in a different system, j. J. Smith junior in another and its bringing all of that together so we know where were touching them. After the report, the task force ended, were in implementation process. Members of the task force are involved and in contact. They came from a community. We didnt feel it with people in treatment programs, some former users that were involved with us to help us formulate these recommendations. One of the things we looked at, prior to coming in office, a lot of the efforts had to do with Overdose Prevention quite understandable because of the surge in actual deaths associated with the disease. But we also said we needed to take a longterm multifaceted approach. We had to, as i would say we have to stop the pipeline of new users. Thats a prevention aspect. Thats the Prescription Drug monitoring that was talked about because new gateway drug are prescription opiates. But as well as what director botticelli said, we have an issue, in terms of some individuals, they start with marijuana, tobacco, alcohol, 70 , close to 80 are coming off Prescription Medication. We needed to make sure we educated populace, people who didnt think we had a problem, and as well as deal with that stigma. And as people more and more people talked about it, they realized their neighbor, neighbors kid or talked to their child, their child knew people who were having these problems or talked to a neighbor and it was their husband or wife that also had the problem. It was an eye Opening Program process that we went through we realize as far as prevention and educational aspects that there had been a gap since80s, a lot of emphasis on d. A. R. E. Programs, Nancy Reagans just say no program. After that there had. A gap in terms of public information. One of the things i would say over and over is every third grader can tell you how bad cigarettes are for you but cant tell you the danger associated with taking someone elses Prescription Medications we set out in october, as part of our interim report, a public information, states heroin Public Education campaign in the local schools. We also encouraged our state board of education to start implementing substance ause disorder or drug education earlier in school and not waiting until High School Health classes to start really talking about it. At an ageappropriate level to start in as early as elementary school, talk about such things as not taking someone elses Prescription Medications. Including it in more classes. Including biology classes, possibly history classes. We had opium wars in this world. It was to try to get more information out. We also started running Public Service announcements with some help from the local universities in terms of setting up a competition amongst local film schools to come up with, develop these messages that could go out to people in their age group as well as older. We had an ulterior motive, one we didnt have to pay for it, two, you get younger people to talk to younger people versus old guy like me trying to talk to them. Those were a membnumber of item submitted to the governor. Probably six or seven recommendations required legislation, so were working through that process. Governor also included additional money in his budget to deal with Overdose Prevention as well as treatment, additional treatment money. And then, in a supplemental budget we added additional money administered through the court system which provides alternatives to incarceration for those who their main issue is that they have a Substance Use disorder. One of our policy people who worked with us through campaign and continues to work with us now used to say and i always quote him we need to make the distinction between those who were upset with and those who were afraid of. Were upset with the person who broke into our car, maybe really upset with person who broke into our car but were not afraid of them. Were afraid of the person who is trying to kill us or other harm to us or our families and those are the people we want in the lockup and deal with the person who has a Substance Use disorder more than anything else. We continue to work to try 0 to address the crisis. Its, like i said, implementation process, education process, not just the publi legislators as well. Talked about ingrating our systems a number of our legislators are saying, why are you putting money into that versus into treatment . Were saying we need this is part of treatment. This is part of knowing who we need to get access to. Their thought often with treatment is only inpatient. Sometimes a person does not need inpatient treatment. Inpatient is most expensive. Making sure theyre placed in the right environment for the issue that they have. We continue to work at that. Its an ongoing challenge. I thank you for this opportunity. Well open it up to questions at this point. I guess i should stand up here. Pretty powerful, governor, rutherford. Governor boesen, its something i talk about a great deal in my personal life. This is nothing new to any of us. My father was an addict and due to chronic pain, he threw his fami family away for it, eventually died of. The piece that i find difficult, im going to pivot to your knowledge is, weve come up with so many other different types of medication in so many other worlds, youre talking about treatment, but the input aspect of it is we dont prescribe tag amet anymore, there are new drugs. My father was a percocet darvon fan and nothings changed. Im curious what you see on the horizon for other nonopium type of treatment thats out there because its what is advertised or whats there that we see on the horizon, in addition to the not soluble type of discussions that a prior panel, governor rutherford talked about those. Both of you can talk about it. Its stunning to me over my lifetime these medications have not evolved to more nowprecision medication. Thank you for your remarks. Youve shared that story about your father. Its a heartbreaking story, but not unusual, unfortunately. Regarding development of new drugs the holy grail that i believe a number of manufacturers are chasing is the nonaddictive pain medication that works as well or better than opiatebased medications because having a safer Pain Management program would benefit so many heartbreaking stories related to people who, frankly, whether they have a genetic predisposition to the disease or the drug causes the disease, we still dont know, tremendous Research Needs to be doen on what the root cause of addiction is what are the modalities we can use to treat it. But that is the holy grail. I know there are manufacturers chasing that. I dont know how close we are. My guess is were not very close yet, but certainly we know that thats the next iteration. Interestingly enough, though, you mentioned percoset and darvon. Percoset is still around, its a staple medication thats used for shortterm acute pain darvon isnt, though. Fda, selfyea several years ago propoxyphine wasnt effective and withdrew it from the market. Researchers are constantly looking at ancient medications and at times taking them away when the risks now outweight benefits of them. Some things do change to the benefit. We dont see it any more, its not on thearket anymore. There was a lack of risk benefit information that was positive. Like i said, pharmaceutical industry with as much villainization as we get from time to time, we view ourselves ace partner on the Health Care Team to try to improve health and wellbeing of people throughout the world and do it in a safe a manner as possible. I hope thats a message that i can relay on behalf of the industry there theres also a lot of research that seems to be going on with the whole medical marijuana. Thats an area, i think, a number of entities are looking into, whether that can address some issues and some of the areas of acute pain. Can i jump in on that . Yes. Absolutely. Really good question. First of all, i think theres three parts to the answer. One is not only is the industry chasing this, but in part of the reason theyre chasing it is because the National Institute of drug abuse is putting out a lot of the money to help them chase and theyre also partnering with universities and other Research Organizations around the country. Nida has a program to help nonopioid pain medications, thats one. Number two is, one of the things that pain strategy does, it points out how underutilized things like Cognitive Behavioral Therapy is, acupuncture, and the like. Really, there are things we know that work for certain people. And kind of making sure those diffuse appropriately as a second part to the answer. Third part is abuse deterrent formulations we have a first generation out there now that is in its infancy but theres new signs in the pipeline that will potentially make abuse deterrent formulations really abuse deterrent and not defeated by fairly easy science. I think were trying to work on all three of those front and theres to be optimistic. Thank you, governor. Thank you, panelists. Youve made some interesting points. I come from mike stack from pennsylvania i serve one of my constitutional duties as chairman of the board of pardons i would say half of the folks trying to get pardons had some drug or alcohol issue in their past, which they say its resolved, so a number of the Board Members are interested in are you in n. A. Or a. A. Or working aprogram . Dr. Boesen, youve made an interesting point, weve gone a long way to believe in a 12step programs are key some folkses are of the school of thought that thats really the only effect everybody way to treat addiction. But there are things that happen in life where its difficult for most people to continue on in that. So weve been at a point where we have actually working against a stigma against people who arent in 12step programs. Woo say to someone seeking a pardon, what are you doing for recovery . They say i pray or im working hard. Usually thats not received well. But i think that goes back into the whole issue of stigma in addiction and were starting to learn more and more things. My own problem is, i still am learning to find acceptance for the idea of methadone because i feel like with methadone, youre still carrying on this cycle of opioid addiction. In some ive said this to addiction specialists, isnt this a remnant of the 70s . Cant we do better than this . I though there is still some places for it. But i think, you knowing what were talking about here, its a growing area where we still were all still learning. Its hard to believe that with this this is a Health Crisis that were still learning. Im with the school of thought, too, that, weve just legalized medical marijuana for, you know, childrens diseases and traumatic injury in pennsylvania. But im one of those believers that marijuana is a gateway drug for a lot of folks. So i guess what ive done again is made a speech. But i really appreciate matts experience. I mean, if we have folks who put that out there, i think makes it a lot easier for other people out there who have the issue of addiction in their lives and in their families. Look forward to working with you folks and, governor, as we go forward. I will say real quick, when putting together our task force and had people coming in who, a lot of people in the treatment community, they come in, 12step works, medically assisted works, me being kind of the not having a bias there, not being involved and just learning the process said, look, we want to have all of the solutions because one size doesnt fit all, which was said earlier. For some people, it may they may need this process. But i agree, i have the bias i have is the concern that you have with methadone treatment, you we would ask, thats why we talked about quality of care, is there a stepdown, is there an exit ramp from that type of treatment . Is it sfrmtaboxone, is it Something Else . From the Virgin Islands. Basic question. Prescription drug Monitoring Program, i understand, is expanded to the 50 states, you specifically said that. Out of Virgin Islands and other territories excluded . I need to know for the record. Well, my understanding is that its statespecific. Why of the states have prescription Monitoring Program, some states like maryland, right now, voluntary. But we have legislation to make it mandatory, mandatory registration and mandatory query. Were still in session. I dont things look good now, with my fingers cross the. I probably jinxed the whole thing. Theres resistance to it, particularly from the medical community but so much on the other side that is putting pressure on them so come to understand this is where were going. I think what the federal was talking about making sure theres more integration with other states. A couple of things. One, 49 of the states voluntarily have Prescription Drug monitoring, theres one that isnt, at least on a glide path to get there. I what were tryinging to do is trying to support one using the best Technology Integrating it with leElectronic Health records so it becomes easy for doctors to track things. If you dont make it easy for doctors, given how busy they are, given how much they have flying at them, youll never get there. Thats where were making our investments. We do, and with the territories, were delighted to work with the territories. Were happy to work on that with you. The other thing that were trying to do with Prescription Drug Monitoring Program make them so you can go across states. A number of states have made great progress. One state can now connect 28 other states, but you know, were moving in fits and starts there. But again, were working with states, about to have a series of regional outreaches where we actually help with best practices on that. Can i make one point . As a pharmacist who practiced for 20 years before getting into the pharmaceutical industry and saw the growth, one of the things id like to recommend to states, as you consider the usefulness of the pdmps, one of the resistance from pharmacists and subscribers, when it comes to mandatory usages, what do i do now . I found someone who is doctor shopping, someone who is clearly addicted. Where are the resources in my community i can get this person treatment . Its stunning, mostly because of the fairly new aspect of medicalized treatment that the people who are on the ground in the primary care set, in the gross store pharmacies, independent pharmacies, chain pharmacies i suspect many of them dont know what to do next other than to say, gosh, im uncomfortable treating you. If you turn them away, turn them off, the disease didnt go away. Theyre going to need to find the drugs from somewhere else and theyre going to turn to the street. Weve got to have a plan and an Education Program to teach prescribers and pharmacists, what do you now, now that you sn know . Thats the next iteration. Kathy hochulrom new york. I have a question. I remember a conversation i had with the head of eight major metropolitan emergency room and i said, when people come into the door and theyre injured and you prescribe opiatebased drug. He said our whole training, dna centered around keeping people out of pain. I responded saying if you knew the temporary relief of pain when they have this injury could lead to a lifetime of addiction and death, why would you keep doing it . He said something i want you to respond we are rated by the federal government. Providers are rated and reimbursements a reimbursements are tied that. Are we incentivizing overprescription because of federal standards if thats the case, somethings got to change. Can you comment on that . Its a great question. There is apart of the answer thats simple and a part thats really complicated. The simple part is two important things that we are in the middle of studying this. Ill give you a progress report. Question one, now much money is on the line if you prescribe more . Say theres a connection between more prescribing, more pain relief, higher ratings, how much would you benefit financially . The answer is, were talking pennies. Not enough money to get anybody ever to change their behavior. Thats one thing. Second part is, when you prescribe more aggressively, do you get higher ratings . There have been three, four studies done of this. The answer is, no, you dont get higher ratings. In fact, sometimes you get lower ratings because, in fact, when you prescribe more, you tend to spend less time talking to your patients. The thing that gets you good scores is talking to your patients and helping them solve the problem with you. Third, having said all of that, per septception is areal. What you pointed out, we hear every day. The problem is one of education and understanding. So, let me pose to you our problem, which is its very important to manage pain. And our major source of data on whether, in fact, were doing it reasonably is those questions on the referring to the hcaps, our quality tracking program. So one thought was, lets get rid of the questions, there will nobody misunderstanding that were not bonusing anybody. On the other hand thats our major source of data how were doing on pain. That would be throwing the why out with the bath water. Really, what i think were going to to is were taking a hard look at how the questions are asked and going to have to go out and educate and work with the Physician Community because, in fact, if they pursue that path, a, theyre not going to get higher scores, theyre not going to get extra money but were going to continue to have our problem. Thank you, governor rutherford, for all of your insight. This has been very helpful. I know Governor Reynolds is collecting a few of the documents weve spoken of today. Not that i want to copy your report but id like to contrast and compare its on our website. Its still there. Ill make sure i get it to julie. Thank you so much. I think that was it. Thank you all. Thank you, panel. On the eve of new yorks president ial primary, Donald Trump Holds a Campaign Rally in buffalo, new york. Live coverage begins tonight at 7 00 eastern on cspan2. Madam secretary, we proudly give 72 of our delegate votes to the next president of the United States president obama dlelivers hs last peach to the white house Correspondence Dinner at the end of the month. This coming weekend, cspan takes a look back at his some previous dinner routines. Heres a portion of what youll see. No one is prouder to put this birth certificate matter to rest than the donald. And thats because he can finally get back to focusing on the issues that matter, like did we fake the moon landing . What really happened in roswell . And where are biggie and tupac . All kidding aside, obviously we all know about your credentials and breadth of experience. For example, no, seriously, recently in an episode of Celebrity Apprentice at the steakhouse, the Mens Cooking Team did not impress the judges from omaha steaks. And there was a lot of blame to go around but you, mr. Trump, recognized that the real problem was a lack of leadership, so ultimately you didnt blame lil john or meatloaf, you fired gary busey. And these are the kind of decisions that would keep me up at night. See the entire speech saturday night at 10 00 eastern on cspan. The program also includes remarks by senior white houcorr of mcclatchy news. Cspan takes you there, live at 6 00 p. M. Eastern. Its one of the biggest social events in washington, and its president obamas final one as president. It features comedian Larry Wilmore of the nightly show. Representatives of the u. S. Special Operations Command Silicon Valley Technology Firm and u. N. Talked about their work to counter violent extremism throughout the world. Remarks part of a twoday symposium held in washington. This is about 40 minutes. Thank you. Yes, i am pamela all, chair of ipsy. And i want to add my welcome to that. Im really delighted to see so many people from so many different sectors and disciplines and so forth who are here today to help us think through the challenges of violent extremism and how to counteract it. As the secretarygeneral said, how to revent it, how to alter its trajectory in a positive way and how to help societies recover from its effects once out of its grip. The purpose of this symposium is to allow us to understand the issues better, to develop different options for addressing the issues and to identify and acquire the skills we must have in order to take effective action. Over the next two days we will be thinking in the service of doing, moving from analysis to action. So this Opening Panel will set the stage by looking at how how major institutions and sectors approach the challenges of countering violent extremism. And our three speakers are brilliant guides in this process. David, im going to introduce them all and then they will just come up one after the other. David solaf is the ceo and cofounder of premise, a San Francisco Data Corporation that collects data and analyzes it in all sorts of social and economic sectors. He is on the Advisory Board of the columbia universitys institute for data sciences. But i did want to point out that his graduate degree from berkeley was in the social, economic and lynn linguistic history. U. S. Navy captain peter haines is a graduate of notre dame, also an historian and also of the Naval Post Graduate School where he got his phd. He has served in a number of combat environments including iraq, but has continued to contribute to Strategic Thinking in the military, currently as Deputy Director for strategic concept, j5 strategy plans and policy at the u. S. Special ops command. Steven seqera is at the u. N. Department of political affairs. He has served in the executive offense of the secretary general focusing mostly on human rights issues and has also been assigned to missions in mali, berundi, the Central African republican and iraq. With that, im going to turn it over to you. We will have some time at the end for questions. So please be thinking about what you want to ask our great panelists. David, well start with you. Good morning its great to be here. I come in peace from Silicon Valley in San Francisco. Were your friends. Its difficult to get a seat on any planes from San Francisco to dulles. There are a lot of close ties being built. So much of our company and customers and markets we serve are based here in washington, d. C. And the d. C. Area. Ive come to know and understand much more intently the important work thats being done. We are a Technology Company based in San Francisco. Ill give you the very very quick over view of what we do. We operate a Global Network on mobile technology of about 50,000 contributors in over 40 countries. A very large developing world footprint, subsaharan africa, developing asia, latin america. These contributors are connected to our infrastructure via an application that runs on their noble device. Were able to conduct vigorous food collection. Our emphasis is on serving the International Development community and we focus a great deal on Capacity Building and supporting National Stats offices and minute tistries of h in their work. So much of what we think about every day is trying to understand the ground truth regarding resilience, social economic infrastructure. We go right to the source to understand what that is, namely the People Living in those locations. Mobile technology, specifically the proliferation of android and low cost mobile devices with cameras, gps, data capture capabilities. Really its martialing in a new era to understand whats happening from the point of view of a citizen. All of our contributors are compensates for their contribution. Its all open source. The foot present thprint, globa working against famine. We collect a significant amount of Economic Statistics information in this new and alternative way. And so the vision id like to paint is one of google maps traffic information. However, rather than thinking about it as a realtime streaming traffic status information regarding your morning or evening commute, imagine being able to access similar type information regarding the types of economic or social pressures individuals are feeling in different locals all around the world. Maybe its what it costs to feed the family in a given week. Maybe its about a civic institutional failure. Maybe its about schools not operating up to snuff or service delivery. What we believe at our company is that this type of information is critical to understanding the social policy in different regions around the world. Formerly its been impossible to collect this kind of information. We really believe that technology represents a forefront of being able to collect this information. A couple more things. Regarding the technology itself, theres three core components to what we do. Theres the mobile network itself, including the software, along with the recruitment and training and payment mechanisms. Theres the large task allocation and Data Processing core of the platform where we work with our customers to define a sample and allocate that at the level of very discreet tasks. We collect that information, process it, check for fraud. We then doing ingdo aggregation. Someone whos trying to think about a potential program they want to launch, building roads or operating clinics. Gives them the fine grained information. Perhaps what the Impact Evaluation looks like. So for monitoring and evaluation and down stream Impact Evaluation broadly, certainly in the International Development space were seeing broad applications. Its really great to be here. Im excited to learn about this field. Its not one we know directly about, but hopefully there will be some interesting conversations to have over the next couple of days. Thank you so much. [ applause ]. Good morning. Sorry about being late to the panel. I was topping off my coffee. It has been recommended to me a couple of times to actually be awake during your own presentation. So who am i . Who do i work for . Im a peculiar animal in the navy. Im a navy captain with 30 years of experience who also has a phd. There are about six war fighters in the navy who have phds who arent in the teaching area. We used to have seven, but one just retired a couple of years ago or so. I work for u. S. Special Operations Command which is located in tampa, florida. Sokom is also a bit of a peculiar animal. It has title ten responsibilities much like the services do to train and Equipment Special Operations forces. But at the same time, it is also what we call a function naal combatant command that has responsibilities in a particular one of socoms responsibilities is to coordinate the planning globally for counter veo efforts for example. I am not a sof operator. Im a strategist. I work in the strategy area. I know we tried to get a two star here to be able to talk to priorities and efforts at the tactical and operational levels but as you could imagine, those guys are fairly busy elsewhere. What i thought i would talk about today is some of the assumptions and believes that undergerd u. S. Special Operations Commands strategic approach. Im doing that because i want everybody to understand where socom is coming from conceptually. But also to hit the lowest common denominator in terms of fundamental assumptions that affect all of us. So steven for example is going to talk about how, i will delve into more of the why. So ill go down through a list of general assumptions thats kind of driving our priorities and efforts in overall thinking. None of this will come as a huge surprise to a lot of you, because as we will find out, for example the need for prevention and so forth, but im focusing more on the why. And the why is really centered and im really context yu conte contextualizing this in terms of globalization. If you understand that, our policies may be off kilter. The assumptions ill talk about today are also generally applicable to our state adversaries as well as our nonstate adversarieadversaries, example, our globalization perspective is relevant because that really provide the deep milieu in which the v. E. O. Organizations root itself for example. So ill go through a list of assumptions and then essentially implications that affect how we think about things. First of all, the challenges and threat es will continue to ievo. In a deeply interconnected and interdependent world, change is the norm. That we have to be able to operate continually in a deficit of information. We have to be comfortable in chaos, we have to be able to anticipate and so you can see where a sof operator needs to be present in the local context as leland noted. We need to be present in that local context to be able to understand what is going on, to be able to provide the geographic commanders and the chiefs those kind of relevant information and options that they need. And thats why i think davids efforts are really key as well. If you guys havent been on davids website, take a look at the folks in his company. I would love to sit down over a couple of beers with some of these guys, computer experts, google,facebook, Just Brilliant guys. So what does that mean . That means we need to be able to anticipate concept yule aual an material changes. For example, if we have sof operators in one area of the world countering v. E. O. S and we move those and we anticipate we may have to move those either in direct action or preventive elsewhere, we need to be able to have the institution behind that operator saying, okay, look, your comfortable with where you are now but were going to have to move you. If you think of sof operators as utility infielders, what does this sof operator need to go from third base to right field and go like that . He needs a new pair of cheats, a new glove, an instruction form to be able to say, okay, this is what youre going to take alook at when you arrive, these are your potential allies, here are the chief of missions, here are their interests and be able to prep those guys. You need an ininstitution behind the operators that are just as flexible and can anticipate things much more than it is right now. We need to anticipate particularly along the seams. Our enemies both state and nonstate know exactly where our seams are, whether its the seams between the geographic commanders or the seams between federal agencies in terms of authoritys knowledge and expertise. I was the director for strategy plans at the command joint Task Force Horn of africa where i recognized a couple of faces out there. And really talk about ipsis bridging the gap between theory and practice, i volunteered to be able to bridge that gap between theory and practice. And i was really taken to school in that context. For example, and where we were in jabudi were at the center of some seams between u. S. Africa command, u. S. Pacific command and u. S. Central command. So for example, when we have v. E. O. S moving from one geographic combatant command and becoming a transregional problem, we are raeealizing tha the structure of the military was not one amenable to be able to anticipate that move and what we needed to do in kind of preventive actions in terms of how we engage the populations there or in terms of a direct action. The second assumption, prevention efforts are preferable to reactive measures as the effects of crisis will spread for rapidly. In a deeply interconnected world, there is no such thing as a local crisis. That local crisis, whether its economic or political, will spread and become a physical a military conflict. If its a conflict, its effects will spread and become economic and political in nature. In 1997 when the asian tigers had their financial problem, it took about a year to radiate to our economy. It is becoming faster and faster and faster. That means that prevention is key. Former chairman of the joint chiefs of staff mike mullen used to say prevention is as important in deterring and winning war and far less costly. Here i am speaking as a strategic historian. Prevention which is really addressing the underlying causes of v. E. O. S is a strange kind of concept for military. Because in many ways what admiral mullen was implying was that the skills to prevent conflict are fundamentally different than those needed to deter and wage war. There are many parts of special operations, for example the green berets, whose purpose is to be more relevant in preventing than in direct action for example. That also means that we need to seize opportunities far earlier in the decisionmaking process than we are currently acquainted with or familiar with. That is to say that we can no longer afford to wait things out and be able to put ourselves in a reactive mode. We need to give the geographic command and chiefs of missions the options well ahead of when they turn around and go, hey, i need some support here, i need some help here. And what that really means is we need to be in place to anticipate things as well. The third one, military problems are so intertwined with political and economic ones as to be almost indistinguishable. There was a time particularly in the early cold war where the military sphere and the Political Economic sphere were actually never overlapped. In an era of globalization dealing with v. E. O. S that are deeply rooted in that milieu of globalization, problems can only be solved collaboratively. We need to be able to develop flexible and specific interest problem solving partnerships much earlier in the process than we have before. The fourth one, the Information Age will continue to the opportunity, speed and methods by which populations and governments are influenced. In an era of globalization what were seeing are that institutions particularly at the local level are heavily strained. Institutions are really the key. Particularly in my experience in east africa, it is not enough to be able to increase the capabilities of the Security Forces of our partner nations. You really need to build those enduring institutions as well. But so what were seeing in the era of globalization are that the costs of governing are increasing while the costs of influencing populations and coercing governments through them is decreasing. So in many ways the high ground in military speak, one of the high grounds in terms of v. E. O. S is how do you counter the influencing of populations . Right now the ability to influence is greater than is the wests failing inability to control to the extent that influence can consolidate gains and enhance governance is yet to be seen. That is so say governance will take a while to catch up. As were seeing now the more Effective Governance is moving down farther to the local level in democracies. The fifth one, adversaries will use all available methods and technologies to counter and reduce our advantage throughout the spectrum of warfare. We cannot expect that state and nonstate actors will somehow align themselves against u. S. Conventional military strengths. Instead they will go asymetric. If it was ever the case, its certainly not now because our state and nonstate actors are greatly enlarging that area between war and peace. Transregional terrorist and criminal organizations will remain persistent longterm threats to u. S. Interests. A lot of people ask me, hey, is the islamist challenge, is that generational in nature . I would say to him, well, syed came to america in 1926. In a basic sense you could sense this recent movement of islam has started since then. Certainly 1979 when preal qaeda group took over, the grand mosque in 1979 for example and had to be flushed out by French Special operations forces. So, yes, this has actually been a generational challenge already. Being a historian, its always helpful to root your understanding in a deeper Historical Context as well. And finally, the proliferation of weapons of mass destruction presents the most dangerous longterm threat to u. S. National interests. I was one of the primary writers for our commanders newly released strategic guidance. He kind of divided up what sof expected to do and what they should do. What sof must do are those responsibilities that sof has unique responsibilities for, namely hostage rescue and recovery and counter wmd. What sof is expected to do is countering terrorist organizations. D. O. D. Has recently turned to u. S. Special Operations Command and said put together a plan for d. O. D. To address transregional terrorist organizations. That goes back to my talk about the structure of the military and some of the limit taations h that. We must provide the full array of capabilities across the spectrum of operations. This is what we need to be able to do right now to put the geographic commands in a position of success in the future as well as the chief of missions. We need nmore transregional sin chronization among the military and we need to rebalance situations long before they become crisecrises. In terms of our current priorities and efforts its all about the ctto,. What we want to do there is execute a series of campaigns to disrupt and defeat transregional terrorist organizations threatening if u. S. And its allies by providing a framework to drive planning and resource organization. I hope that provided some context to how were thinking and i look forward to the questions. Thank you so much. [ applause ]. Good morning everybody. Im hope this will work. We didnt get a chance to try it. Ill try to speak for about five to seven minutes and then open the floor. My name is steven siqueira. Youll notice the term prevention and the secretary general coined that term last year at the white house summit. Very very pleased this morning to hear the speakers from the leland to our military colleagues to others speaking about the need for prevention. The secretary general in the start of his second term actually made prevention having realized after five years of fighting fire after fire that we really needed to try to move the ball forward and further upstream in the areas of conflict prevention and Disaster Mitigation and also terrorism, what are the roots, the drivers and how do we get at those drivers. The context is very apropos for the u. N. And were wellplaced as the universe al organization with 193 Member States to help set the framework for some of these issues. Were seeing terrorism have an impact on all of the areas of our work, which is the peace and security and also the shock and awe Human Rights Violations were seeing from isil and boko haram in west africa. Were also seeing the impact on Sustainable Development and the passage of Sustainable Development goals late last year oent be achieved by 2030 if we dont do something proactive to defeat violent extremism. Also were seeing the migrant crisis resulting from wars and conflict and also the real fear that people have that groups like isil are taking over their homes. The secretary generals agenda has many antecedants. And defensive operations. There was a review of the peace building architecture, the 2030 agenda for Sustainable Development. The paris accord on climate change. The women peace and security agenda. Security Council Resolution 2250 on youth engagement. The human rights up front initiative, which is to put the pendulum for the International Community on human rights for this period of his last few months in office certainly but also during the last two or three years. Then the world humanitarian summit coming up in may. This is all converging. As the secretary general said in his opening remarks there is a major conference happening starting tomorrow in geneva where we have 40 minuisters delegations talking about how to talk about effectively preventing violent extremism. It did very much look at the drivers of violent extremism, recognizing that the complex variety of drivers that make and lead individuals to commit such heinous acts wlr, whether its lack of social economic opportunities. But then also at the pull level for the individual was there some kind of sense of collective grievance. Is there a sense of oppression or perceived injustice for the individual, where that rubber meets the road for their individual or their father or their mother where that individual intersected with the state where the police are seen as corrupt or the Government Official is seen as unfair. Those are the individual pulled factors that are very difficult to quantify. Maybe some of the speakers this morning and davids work might help us to understand some of that. Similarly the prevention of s subjugation. We have to take a humble approach and work the local leaders to develop national and regional plans. The secretary general through the review of what has been tried up until now came up with seven areas where National Governments may choose to engage and develop their National Plans focused around dialogue and local prevention. Strengthening Good Governance and human rights and the rule of law. Engaging communities, which weve heard a lot about, which is very very important. Empowering youth. One of the things the secretary general discovered and all of us working on this the last several months, the gap in programming for youth. I think we can all recognize that, that unicef deals with childrens issues. Unpd deals with engagement of young adults. The real hole in the International Community is how to Channel Resources to youth groups and to build space, whether political, community, any type of space in local governments for youth engagement. Gender equality. We found that u. N. Women has supported us with this research where it seems to be the case that those societies that have higher eer indexes of gender equality have higher rates of extremism. Recognizing that just because people have jobs doesnt mean they wont necessarily follow a path to violent extremism. Again a lot of research has shown that that is not by itself sufficient. Strategic communications, again, theres been a lot of discussion on countering the narrative. One of the areas wed like to focus on today is how do you actually create alternative narratives and how do you have compelling narratives . Young people arent going to be duped. We have seen some exercises by National Governments and others where theres a very honest effort to counter narratives but young people dont listen. Young people will find that alternative narratives on their own. How do we do better at supporting them in doing that . And comprehensive approach. I think we heard about fishers, how violent extremist groups will exploit fishers in our bureaucracies and society. Therefore you need all of government and all of society and from a u. N. Perspective were going to try very very hard to do an all of u. N. Approach in implementing some of these ideas. There will be a review of the global Counter Terrorism strategy in june. We hope the General Assembly will come up with an outcome con s consensus and support of these ideas. Thank you. [ applause ]. Great. That was very interesting. Its interesting to see how these major institutions are showing a great deal of flexibility in reorganizing themselves to address these problems. I believe we are on a faster schedule than we thought. We have about five minutes for questions and so im just going to start taking them from the floor. Lets take three at a time and see how many we get through. Youre the first person i saw. Please introduce yourself. [ [ inaudible question ] you can see push pull on my powerpoint and not copying your model. Academic terminology. If you notice that along with some of the arab countries, the biggest krucontributors to isise france and belgium. Are you also focusing on European Countries even the u. S. And looking at it or this concept of bad governance being a third world, middle eastern thing . Thank you. Can we go to another question . Other questions . Please. My question to captain peter, id like to you conveniently over looked the idea of the mujihadeen. You said theres a generally terrorism and the attack on the grand mosque on november 20 th, 1979. Dont you think this was a red flag for the countries like saudi arabia, United States and pakistan to be very leery of giving the fight against the society and islamic term mujihadeen . I think this is really the rise of modern terrorism or islamic terrorism from that date. Thank you. Thank you. Please. Chuck woolery from the united nations. I compliment you on everything you said so far. I grecompletely agree with it. Ive been agreeing with it for the last 15 or 20 years. Show me the money. Where is the money going to go into effect to protect human rights effectively in terms of preventing these crises instead of continuing to respond to them . Do you want me to go first . Ill try first. On the question of governance. Governance applies globally. The secretary generals plan applies globally. We see this problem as a global problem. Yes its true there are pockets of issues that need to be addressed more specifically in certain countries. In the case of European Countries, in the case of this country in the case of my own country canada, theres questions of marginalization and the questions of what is the best approaches to do that. And i think those are the questions wed like to move forward on with governments hand in hand and also with local communities. But the secretary general certainly given that hes the secretary general of 193 Member States is not going to point fingers at anyone country. Hes making the point that if you dont have political space, if you dont feel engaged as a young person, then youre going to find other ways to reflect you opinions. Thanks. Great question. I think and it goes to my point goes more towards the american predilection to problems that are new and shany. I think youre correct in the sense that we thought about the Islamist Movement in a cold war context and then in the post cold war period, that kind of ebbed away. We did really understand the importance, the longevity and so forth. So i think in para dynamic terms in terms of modern terrorism the change has really been in our paradigm, our post cold war paradigm and were finally out of the shadow of the cold war after20 years or so. Its interesting to look back longitudinally to trace these things. Thats not how americans think. Americans send to be very ahistorical in nature. I did want to add one comment regarding global versus local. We tend to take a local approach given the nature of the technology and given how we acquire information many of the programs and many of our Program Partners are focused on very local everyone lempimplementati. A set of clinics that are in a certain district, whether a Deworming Program is being administered correctly and whether the impact in that local is tracking according to plan. For us, all of these local or hyper local measurements can be stitched together to form a broader measurement. I know thats not directly on point to the first question but its how we think about the problem. Regarding money, if you find some on the eve of new yorks president ial primary Donald Trump Holds a Campaign Rally in buffalo, new york. Live coverage begins tonight at 7 00 eastern on cspan 2. Our live coverage of the president ial race continues. Welcome to hudson institute. Welcome, all of you. We welcome our cspan audience, too. I wanted to welcome, also, the panelists were very proud to have a wonderful panel as we often have here. Im going to talk about the subject in a moment but first i want to introduce the other panelists and say briefly the kinds of things that theyre likely to touch on. To my immediate right is joe, a visiting scholar at the Carnegie Endowment for international peace. Hes also a former policy Planning Consultant with the French Foreign ministry. Joe and i first met in beirut about ten years ago now. More. More. Yes, youre right. More. Wow. It is a pleasure to have him here, a pleasure to welcome him. It is a huge honor to have him here. To his right, jamana, her first time at hudson, too. We welcome her. She is a policy analyst at the u. S. Commission on International Religious freedom. To her right is my colleague here, michael doran, a senior fellow. I am also a senior fellow here, and also a Senior Editor with the weekly standard. Panel that we have convened today is syria five years on. Were going to touch on some of the relevant issues that you see unfolding before you right now. I think that joe is going to be able to give something of a regional perspective, and also something of a european perspective. Jamana will talk about a number of sectarian issues at play on the ground. Mike is going to speak from a u. S. More of a u. S. Policy perspective. This will certainly be one of the things we will be talking about, what it will look like for the next administration, the next white house, what their policy choices will be in syria. But i did want to start by saying it is five years after what began as a peaceful uprising in syria when people took to the streets across the country and the assad regime started firing on them. Its important to remember how what we now commonly call a civil war started as a peaceful protest movement. It was the assad regime that turned this in to that initiated the hell that we have been watching unfold the last five years. The way that i look at whats been happening in syria, what its turned into the last five years, we are looking if youve seen people talk about the isis campaign of genocide against christians and yazidis and other minorities. Lets keep in mind the preponderance of violence has been assads and its waged against the surabaya arab population in syria. It is very important to keep this in mind. Players in washington would like to divert attention away from that and other International Players but this is a key issue. The other two things that syria has turned into is a massive war, a multiactor war including state and nonstate actors and now continues to draw in other players including most recently russia. The final thing the syrian conflict represents at this point is a profound refugee crisis thats affecting both europe and the rest of the middle east including lebanon, turkey and jordan. What were watching unfold, i look at the most profound humanitarian catastrophe so far of the 21st century. We havent seen anything like this since the breakup of the former yugoslavia. Except even more profound, it is affecting two continents at least, rather two regions of the world the middle east and europe. And i have little doubt that it will have profound consequences here in the United States as well in a number of different ways. So with that, again, i just wanted to remind us all to bring it back to how this started a little more than five years ago in syria. So joe, i believe you are going to open up first. So thanks very much for being here. Start off. Thank you very much. Im really very honored to be here today, first of all, congrats for your fantastic new venue here. Thank you. It is beautiful. Im also very, very happy because it is the first time i am doing something with hudson but i am also very humbled and a little bit moved to talk about something that has turned out to be an endless bloodshed now. Were reflecting on five years after the start of a syria revolution that started very promisingly. It was the midst of this arab upheaval, arab uprising, call it as you wish, arab spring or something, that was really bearing promises of change in the arab world. Today were stuck into something that is much more, unfortunately, murky and muddy. What i would say is probably very much in line with your points. I would try to say two or three things that oscillate between the regional, international and the local level in syria, just to put the broader picture. And then my colleagues could get into more detailed analysis. First of all, the first i think very strong takeaway that we are faced with regarding syria for the last month is, mainly since the beginning of the russian intervention, end of september, is that syria is today quite exclusively a duopoly between russia and the u. S. I think all the other actors are are at least for now, a question mark is how long and what could happen after, but they are today monopolizing at least the International Diplomatic grammar or the tango around syria. They are the ones who are holding the keys. This is very transparent in the u. N. Process, in the geneva process, in the wordings of the resolution, be it 2254, 2268, et cetera. Now the second important thing in that respect and this is i mean im saying it very coldly without any political intent is that within this geopolistic structure of the management of syria you have very clearly a u. S. Subcontracting to russia of the syrian issue. And you can see it very plainly on many levels, the way that the russians have obtained theyre drafting the exact drafting of resolution 2254 and 2268, the fact that kerry didnt take more than 30 minutes to concede to lavrov that would bar any reference to the real delegation, for example, to assads fate that is i think now officially accepted. I mean reuters had a paper yesterday saying that the u. S. Has really conceded that the next round of talks would not address the assad issue. So there is an entire set of concessions, probably mike will discuss that, that indicate the kind of subcontracting from the u. S. Diplomacy to russia over syria. Now it has several meanings, of course, and it has several implications. I think that part of which this very strange announcement of drawdown from russia and syria which is not exactly a withdrawal in terms of military i mean reality is the fact that probably russia took what it really wanted in fact out of this intervention, which is partly to do with syria but not so much, but partly, but mainly has to do with the win of moscow to really become the power of the u. S. On the international scene. And we are at that point. Now it is an illusion, it is something that could fade away, but today this is it. And it has a lot of set of consequences for syria. This brings me to the more local dynamics. Probably, as we say in economics, everything held equal, the truce will hold probably for a moment. Now a moment in syria is five, six months. Not more. And this period is not a coincidence. It is indexed, i feel and this is my analysis on the change in the u. S. Administration. So until the last day or the last minute of obama in the oval office, probably this kind of illusion of truce will hold. The truce is not holding and jamana will say a few words about it concretely. But both parties, americans and russians, and the u. N. , are saying it is holding so we are presented with the reality that it is holding. Now we have to accept that it is holding relatively which is something good on the humanitarian level. But what it means in terms of local development in syria this is why im bitter five years later i think that what we are heading towards today is exactly a kind of frozen conflict. This is something very familiar to the mind of the russian strategists. They have a frozen conflict in crimea, ukraine. Now they are having one in syria. This frozen conflict has several functions and uses for them. First of all, it allows them to wait for the next administration and to see what are the bargainings possible with this new administration. Second, it will consolidate the front lines and the divide lines and demarcations. And this is a real potential drama for syria. It means that maybe were not heading toward partition, but in the de facto sense of the term we have now a fragmented syria. We have, more or less, an assadstan, which is a marginal question if assad survives. It is no more important. You have a kurdistan thats been announced two weeks from now officially. Of course you have verbal positions from washington and moscow saying this is a breach to the political process but in fact everybody is protecting kurdistan. Then you have this kind of very murky, very strange and potentially very dangerous sunnistan in the middle which will become in time the quagmire for radicalization and greater centralization of if not isis but other factions and whereby you will have isis fighting with nusra, isis fighting with nusra, others fighting with seculars, et cetera, et cetera, in a kind of really, really somali land scenario. My bet is that in that respect and i come back here to the external scene. In that respect, we have now a very deadly game between moscow and washington, each one waiting for the other to really become exhausted and come back begging for the other. I think the palmiera battle that we had two days ago is an exact example of that. As soon as the palmyra dust was settled, as soon as the chanceries and diplomatic circles, the discussion became what about raqqa . Who will take the lead on raqqa . Will it be russia or a combination between the u. S. And russia . I Wont Disclose secrets, but for example i receive messages from my former french employers asking whats the mood in washington, are americans also ready to give raqqah to the russians as a line of in this line of subcontracting, which would in fact be catastrophic for the syrians because it would completely achieve to rehabilitate the assad regime for a while. So this is on the local level. Now given this very dark and gloomy picture, what could derail this . I think two things. One which is i admit my naiveness on that. One which is the local reality. You have witnessed that as soon as the truce was in effect, very few hours after, syrians went down back to the streets. So it is as if five years of bloody barbarism. Five years of really kidnapping of the Syrian Revolution by radicals et cetera, the syrian nerve is still alive. People went down to the street the first friday asking for the fall of the regime as if we were in march 2011 still. And the second friday clashing physically with al nusra in several villages which is, for me as an observer and as a supporter of the syrian cause, really a motive of optimism, meaning that you couldnt you will not be able to put a lid on that story. And i think that this is something people in washington in the oval office, in moscow, even in the palace in damascus should reflect upon. You will not be able to shut this off easy. This is a motive of optimism. I dont know how it will play out. The second thing that can derail this kind of frozen conflict is the regional actors. I think kind of paradoxically both iran, saudi arabia and turkey have an interest of not seeing this situation consolidated. Turkey cannot accept a fragmented syria. It is because of surd kurdistan. The saudis will never accept that at least damascus is still in the hands of this regime. And iran will not easy to accept that the partial or the main winner in this relative, lets say, march is russia. They have invested a lot in the syrian regime. They would like to find their investment down the road. I dont think theyre very happy to see that putin is long calling the shots on that. Now what would they do . What could they do . It is very limited. Turkey is now really on the verge of severing completely its contacts with syria. Talks are in the coming months it will have to find another way to have a link with the Syrian Revolution. The saudis are a mystery at least for me. They are entangled in yemen. They are speaking loudly on syria but with a very few very real gestures and actions. They dont want to clash with the russians. They is something they have announced. And doing is in that respect is taking a risk of clashing with the russians. So they have a very limited margin of maneuver. But i think with time they will all bet on a kind of slow and gradual erosion of this long truce and this fragmented frozen conflict. To conclude, i would say that and this is i say it very bitterly and with a lot of, lets say of sadness. Five years later, syria is no more syria. I mean were talking about something much wider than syria. It is a regional, International Conflict at one point, and in some shades it is a planetary conflict. I think that syria will really define the order, the international order, for the days to come. It is an enormous tragedy. Im not saying it emotively. It is a real geopolitical acknowledgement. It is no more syria. Second, i think it is still open to a lot of surprises and bad surprises, and at least ill close on that at least as long as the local reality, the regional conundrum, this tension between iran, saudi arabia, turkey, et cetera, is not squared off, and as long as there is no real parity between the u. S. And russia on that issue with a stronger leverage for u. S. Diplomacy to stand on its own words on Political Software to stop syria, as long as these three levels dont coincide im afraid syria will unfortunately become and stay an open wound and i fear in five years from now well have something of the same talking about syria ten years later. Joe, thanks for a very moving and very concise introduction, also touching on a few points. One of the things i am reminded i wanted to come back and speak on particular, looking at lebanon, what will be or using lebanon as an example, what are the kinds of things that we might be able to look at over the next five years in terms of pace, or rhythm . Because we do see the temporary truce right now. What are the things that may happen . I well come back to that. If you would like to follow up. Sure. Thank you again for giving me the opportunity to speak. I wanted to just take a little step back because my job at the commission focuses really on talking to and understanding the grievances of many of syrias ethnosectarian communities. As joe alluded to, the issue of partition is very much a real issue. The word federalism has been thrown around so it is really important to understand what a lot of these different communities are asking for, what they are looking for. I really want to emphasize something you said in the very beginning which is really to dispel the notion that ba al assad is a protector of the minority, that he is a stabilizing force in syria when in fact he is the opposite. This is based on what minority communities have told me through my work at the commission. At the beginning of 2011, as many of us now know, Bashar Al Assad made a very concrete decision to release many extremists from prisons that then led really to the islamization of the revolution. They went on to lead isil, al nusra, and others. At the same time that he was doing this, he really deliberately used sectarian divisive sectarian rhetoric to really inform and make sure that if you did not send your sons to fight for them, the sunni majority would eradicate them through syria. Weve seen this in many instances. The Syrian Government has relied on its ally iran to help orchestrate the forced displacement of sunnis and removing shia to damascus and thats really to buttress this stronghold assad stronghold in the capital of syria. Recently in an area also in damascus, Bashar Al Assad gave the sunnis the syrians but mostly sunni population in this area an ultimatum that if they did not leave within 45 days that they would be forcibly removed. On voice of america recently said that iran recently announced it was encouraging Construction Companies and whatnot to come and construct this area, build it up. It is no secret this will likely be populated with people very much pro assad and in good favor with the iranians. The Syrian Network for human rights has been documenting a lot of the violence. It reported that 90 of the 56 sectarian massacres that have occurred since the beginning of the conflict were indeed carried out by the Syrian Government itself. It prevented many sunnis from returning to their homes in areas where there is really regional diversity. So as to prevent to sort of carve out these areas like joe was saying that could be part pro shia. I really struggle with proshia. Assad has i really struggle with convincing people that assad is not a friend to the christian groups. Weve talked to many Christian Communities, both in the north and in damascus. Assad has targeted 63 of all churches in syria. He has attacked 166 places of worship, both, from all sects. He has killed around 50 christians but has detained over 450 christians. This is just what we have documented. There are many others that have been obviously arrested that havent been documented. I want to just move over quickly to isil because obviously thats captured the attention of the International Community. Of the 5,800 people that have been killed by isil since 2014, 97 of those were muslims. That isil attacked and killed. Thats a very significant number to keep in mind. About 100 individuals were of minority decent. About 50 christians were of that number. This is not to downplay the threat that isil poses to Christian Communities and others. Obviously all churches have been closed down in isilheld territory. Christians do not feel comfortable. For example, not wearing the veil in areas where isil controls. But its really just important to understand that isil is really the enemy of all humanity in syria. Sunnis, shias, christians and others. Moving really quickly just to the armed opposition, there have been instances im not going into detail but some instances of the armed opposition carrying out sectarianlike crimes. When we saw when islam arrested and caged 700 allawites and it was publicized in the media and the very next day the allawites we released from the cages. In talking to people, they told us that was the only day whereupon which i think one person died. I mean, the government was very cognizant that the International Medias attention was on this area so, therefore, did not attack this area by aerial bombardment and it resumed its aerial bombardment the very next day after the medias attention went elsewhere. About the kurdish attacks excuse me, the kurdish groups. Joe has already mentioned them briefly. There is obviously attacks reports of ethnosectarian violence and ethnic cleansing. I would say just as an analyst i dont think theres enough evidence to report conclusively what exactly is happening in the north. Theres obviously been some displacement but human Rights Groups are still collecting that kind of evidence to support or dispute that. Moving on just quickly to the issue of the cessation of hostilities. In the past month, what weve seen, its been one month and two days since the cessation of hostilities has gone into effect. There has been an 85 to 90 decrease in violence which as someone who was really working in the humanitarian field before i came to the commission is a very significant number. You know, from talking to people inside of syria, theyll tell you that its the first time in about five years some people have been able to go to sleep. Its very significant that the violence has gone down. Now that being said, 91 of all violations have been carried out by the syrian regime. We have 468 out of 512 attacks that have been missiles and whatnot have been carried out by the syrian regime. 32 of those attacks excuse me, 32 attacks were carried out by the russians, 8 attacks by the armed opposition and 4 by the kurds. Another violation of the agreement was detainment. The Syrian Government has also violated this. 333 individuals were arrested in this month, alone. And the last stipulation in this cessation of hostilities was also the delivery of aid and not hindering the delivery of aid. And we have reports that weve heard that i think there was refusal of over 280 deliveries to places that have been besieged. I mean, my own birth neighborhood in syria has been besieged for over three years. It has not received it has not been able to receive any medical or food aid, even now. 370 people have been killed during this month which is unfortunately the lowest fortunately or unfortunately, however you want to look at it, is the lowest number that weve seen over the last five years. So that, too, is significant. As joe mentioned, the protests i want to emphasize also as a syrianamerican, a very proud moment of seeing people go out into the streets for the first time in two to three years. Since 2012 we really havent seen protests anywhere near this type. Men, women and children. I think whats significant from talking to individuals also in the Syrian Nonviolence Movement who have been sort of behind the scenes in orchestrating a lot of these protests is that these individuals out protesting in syria are not necessarily the individuals we saw in 2011. Many of the individuals out in 2011 were killed, detained or fled syria. So were seeing a new wave of people that are out in the streets that are still carrying on the message despite having seen their comrades, you know, fall or flee the country five years ago. So i think what joe said really needs to be underlined that this is not a movement that has disappeared despite the horrific humanitarian conditions that weve seen and the violence that half a million, at least, people that weve seen die. They havent given up. They have stood in the face of Jabhat Al Nusra and it was significant after they arrested people from the protest, they still went out and were protesting against Jabhat Al Nusra even until today. Just going back briefly to the delivery of humanitarian aid, about 30 of people have received some type of humanitarian aid in the besieged areas. Thats if we consider the number of besieged as half a million. There are reports that its up to a million. But these are like oneoff deliveries. So this food may only last them for four or five days, whats meant to feed one person is being divided up for three people. Its a very critical issue and i think its one that the team and others in the issg are really paying attention to. Its one way that they can sort of hold assad accountable based on the security Council Resolutions that the United States and russia have really passed and, you know, are standing by, according to their own decisions. You know, its a real shame especially on this issue because you have people we have seen die when there are aid warehouses less than five miles away. We have doctors in homes like i say, back to my home city have told us they have not been able to sterilize any of their medical supplies. This is causing really unnecessary diseases that could be easily prevented. Moreover, during these deliveries, these aid convoys, the 10 to 18 areas excuse me, the 10 to 18 shipments that have made it through, you have supplies that are being like machines that are being delivered but the assad regime is consciously taking out critical supplies needed in order to operate these machines. So its really hindering this process in a way that is just very its absurd on a very basic human level, and i think its something i hope the United States continues to put pressure on. From what ive heard, as of april 1st, that the regime is going to start being held accountable for allowing or disallowing aid convoys to enter. It has to excuse me. So it has to basically give an answer within ten days as to whether or not these aid convoys can go in. Theres really no good reason for an aid convoy not to go into a besieged area. So, you know, folks on the negotiating committee are saying this might be one way to hold assad accountable, that the u. N. And issg could hold assad accountable by placing this sort of tenday limit. We have the crisis along the turkish border. We have about a million syrians that have been there since the border closed four to five months ago. On the jordanian border 4,000 to 5,000 syrians that are also stranded in the desert. The last thing ill mention and this is something i hope joe can actually expand upon since its more on the regional level but the issue of who will be able to take part in any next steps in russia. Weve heard assad say hes going were going to have a constitution ready by august and parliamentary election in april. I mean, obviously many of us look at this, this is a very absurd idea. But the idea of who will be allowed to have a voice in this is very critical and i think its something that needs to be emphasized. Syrians on the ground are very much paying attention to this because you have many, millions of syrians who have expired identification cards, expired passports. And this is an issue that we have to deal with. So, you know, in conclusion, i think, you know, really going back to, you know, from like i said, drawing on the work that i do for the commission is really emphasizing isils crimes not only against syrias minorities which are incredibly in a vulnerable position but also against the many sunnis that have already suffered and continue to suffer and be very much a target because they dont espouse isil beliefs, and also to really hold to encourage our own government here to keep pushing the Syrian Government to abide by the u. N. Security Council Resolutions that are really critical just on a very basic humanitarian level. Ill stop there. Jomana, thank you very much, both for your presentation here and also for the really important work youre doing and the information youre able to give us. I wanted to reemphasize something that you said before when you started off by saying Bashar Al Assad is not a protector of christians, and i think its important to emphasize that not only because not only because its not true, because hes not a protector of minorities, but also im concerned every time that that phrase has residence in washington or in the United States. I feel thats not or in europe. Anywhere. I mean, i cant you know, thats europeans, its up to the europeans. But here in washington, i