Transcripts For CSPAN3 Politics Public Policy Today 20140801

What does that tell the public at large . Belligerence. You cant ignore the perverse events like this on perceptions. And you cant ignore perceptions. You cant govern without people. Its not good enough to say the right thing. The question is can you carry. And, you know, in light of the experience and failed experience of diplomacy for the past 30 years, its very difficult for me to see the palestinian framework as is able to carry. And thats the bottom line. Thats the bottom line. That cant be ignored. You know, what im saying to you here, that drives people away from their comfort zones. This is not really i would exclude myself from many. But look, there is tragedy going on. And it will repeat itself, time and again. And there are consequences to failure. You cant keep doing the same thing. And really in the process do nothing more but kick the can down the road and pretend that you can go back to the old framework and do it. You just cant. Im sorry if this pushes some outside their comfort zones. Now, how is a question. How can we do it is the question. Its not that were starting from principle with the luxury of designing things to the liking of everybody. But we need to take into account, you know, these complications. Well, lets go to the how to do it question because it seems to me that youre saying very passionately and articulately this vicious cycle were in cant continue. And violence pays off and were also experiencing unprecedented violence. It sounds like youre prescribing changed representation in the palestinian part because its necessary and its urgent. But without saying specifically what that should be. And the changed framework without saying specifically what should be but just saying that it has to change because its not working. But youre not being specific. Youre not prescribing a new framework. Ill do what i can to be more specific. I dont know if i can be too specific. For the reasons what i have in mind is a set of ideas im putting out for consideration. What or the extent to which well be successful and start a discussion on this is important here. And i think its really up to, you know, various factions, whether domestic or foreign to somehow coalesce on something. What im really talking about here is, if you will, the broad architecture of this but not the specific details in terms of, for example, you know, i talk about timebound commitment on nonviolence. What does that really mean in terms of length of time . The concept is there, but its really up to all concerned to define it. But the idea is the following, the substance, to be more specific, it needs to be adjusted. I started to make the point that adjustment was necessary, but then in what direction . What does it really need . First you have a plo as a matter of course and legality and national legitimacy had entered into an agreement going back in 1993 that has a great deal of significance. That cannot be ignored. And the power to represent was certainly there. It continues to be there today. But then what do you do to make that adjustment . My own suggestion would be to leave the plo alone. I mean, do not really get to the point of saying lets undo this or, you know, open it up without any criteria anywhere that makes International Engagement very difficult if not downright impossible. Just keep it as it is with its right to represent in the way thats referred to in those agreements, but in a way that has come to be known, leave that alone. But in parallel, in parallel, having a unified leadership framework that involves participation by everyone. You know, old fashioned. Whether there are plo or nonplo. Theyre all sitting at a table. And there together collectively are to inform decisionmaking by the executive committee of the plo. What does it really mean . Is this really asking too much . Lets just say that the plo doesnt like that or doesnt want to do that, lets assume. This is just for the sake of argument. I dont think they would. But you know, what is the basis for the plo or for the plo to continue to engage in International Diplomacy when its not sure it will be able to carry. You know, again, we could really choose, you know, the kind of game we would want to play. But were not going to deliver results unless we have good answers to the questions. It is in the interest of the plo and its leadership, tourism. To really have its decisionmaking process in full. In order for it to be able to secure the consensus needed in order to deliver an agreement. You know, this is not going to be just an agreement between two people. This is a formality of it. But is it going to be delivered to a point where it is going to be this moment . Something theyve lost their life for . Its very important to prepare and not to continue to pretend. So no, i dont think should. And i think it should welcome it. What kind of processes are involved . And thats why i say this is really open for discussion. This is as much intended on our own domestic Political Team as it is international. Ideas. Exactly how were going to concentrate ourselves in order as a consequence of dialogue thats taken place to achieve reconciliation. How to authorize it in a way that meaningfully informs the decisionmaking by the plo which continues to serve. Thats one element of this. Another is how to govern domestically. Anyone out there who thinks there is going to be an end to this conflict and palestine emerging. Without gaza, you dont need to really rethink the position. Its not going to happen. Its not going to happen. Look at it from the point of view in israel who are in favor of a twostate solution. Clearly, the element is based on the kind of government and country they would like to have. And so demographics are important in that argument. And time and again, ive seen one after another making the case for a state of palestine. Without gaza, if you take gaza out of that mix, they will its very important. So what do we do domestically . We need to have all of them adequately presented. This is in the interest of everybody. And at some point, two final elements. One that needs to be basis for there is a Critical Mass that is absolutely necessary in order to permit a takeoff here. Especially on security. It would be a case of two missing ingredients. Something needs to be agreed. And so far as violence is concerned, i think there really needs to be an understanding of the need for there to be preventable violence. How long . Let that be discussed and agreed. Thats in the interest of everybody. And use the time on the palestinian side. Use the time to rebuild. Use the time to reunify the institutions of the people. Gaza and the west bank have been separated for seven years now. Theres a lot of work that needs to be done to unify institutions. You put all of these things together. Lets say a consensus could be formed on these critical issues. Thats when we should feel powerful enough to go to the israelis and the International Community and say this is what we have. This is what we can and expect to do over the next period. Can we now and this is really the most critical, the adjustment thats intended to deal with the design flaw in the overall framework. Can we now agree on a date certain for ending the occupation . Thats how you really put all of these elements together. Can we agree on a settlement for action . We cant keep on going like this. We need to agree. The default to failure to negotiations cannot be denied occupation. This has to be the certainty of an end to an occupation. Can we agree and then work backward. And then the International Front will begin to proceed with the degree of a sense of coherence that makes sense to the people. And thats we important. For us to expect the process to succeed and deliver. Dr. Fayyad, thank you for that. Some in israel would say and lets come to the present tense, the situation on the ground. Some in israel would say to break the cycle is to defeat. Hamas once and for all to ensure its safety. Thats exactly what Michael Orrin argued in the Washington Post recently. Last week at the aspen security forum, Lieutenant General michael flynn, head of the dia warned if hamas is totally defeated in the current round of fighting, its likely that a more extreme group would rise in its place. Id like to know your vision on this. And i know your job is not to advise the Israeli Government, but what would your advice be to the Israeli Government in this sense . You know, you see the popularity figures of whats going on right now of netanyahu rising. So first this question of what replaces hamas would be more extreme. This tension between say what ambassador orrin said and the head of the dia. And secondly, if you were sitting in a room advising the israel government, what would you say to them . Id say stick with it. This notion that somehow youre going to really continue to engage in this escalation until it leads to the alienation of hamas and other factions of the same kind, apart from the tragic consequences and implications of continued fighting of the kind that has been taking place. This is not really a small matter. I mean, were talking about peoples lives. And loss of life that simply cannot be tolerated. This is completely unbearable. And then what . Everyone has to remember that we are dealing here, at least so far, with unsafe actors. You know. Hamas is in control of gaza for sure, has been since 2007. Understanding the unity arrangement that was brokered recently or agreed to recently. Effectively is there. But still it has not acquired the status of a state operator, a state. And this is really a quandary. Not only insofar as factions of the palestinians are concerned, but other activists of the world. A criteria of winning and losing, you know, are different when you are dealing with state actors. Weve seen this happen time and again in the United States with a country like afghanistan, for example. In terms of firepower, you know, bombing and the rest of it. The situation is like this. We talk about survival of a few. Who after the extensive damage, loss of life and misery and all and say we won. What are we going to do about Something Like this . This is serious. And lives are at stake. With futility. Absolute futility. Thats number one. Agree with hamas and likeminded factions is not as significant as realizing the need for any palestinian leadership to carry in order for that leadership to deliver an agreement. And you simply cannot ignore the ideology. Even if you disagree with it. Thats the kind of work we live in. These are the kinds of standards by which developed and advanced countries you will live by. It isnt a set of standards for the developed advanced world, another set of standards that should apply to others. Its time for all of us to be taken on board. Then i think it should not really be beyond strong leadership, enlightened leadership. To accept that at some point somebody needs to pay for failure. This is not 1990 or 1991. More than 20 years past oslo and more than 15 years past, you know, the end of the time line under oslo. And to somehow pretend that were just starting this and to really take a purist approach to this in a matter that conforms to the highest standards, what someone would like to happen is, i think, extremely unrealistic. Nor i believe would be right and that is really important. Inclusiveness. Inclusiveness. You need to include and you need to govern in a way thats effective enough to ensure that there is sufficient support for that which we stand on. Otherwise we should not be there presenting to the conflict. This is essential to what were looking at. Its a necessity, in other words. But to think, you know, this way is i think is constructive and productive. Unfortunately 1,000 more lives and more suffering, people come back to the same conclusion. Its not hamas, per se. Its that ideology. What do you do . What do you say to people who look at the record over the past 20 years and tell you what have you done for us . What do you tell them . Forget about hamas. Lets just put hamas aside. Unless youre able to be convinced and to make sense when you say, you know, we have an alternative. You need to really provide an answer to that question. Hamas or no hamas. If a solution is what youre interested in, we need to show enough courage to be accepting, of being pushed away from our comfort zones in the direction of finding something sensible. Finally, on the other point that you raised, the region, and i sort of alluded to this in my opening remarks. Really when it will end and how it will end, only god knows. But there are very few people i know who would have expected things to be the way they are today. But they are. I mean, in terms of extremism, violence. This is unprecedented, and i think defies expectations of many in terms of whats going on. The degree of extremism, you see this, extremely grotesque and certainly alien to any kind of decency if you really think about it this way. What do you really need to do to somehow understand this and prevent this becoming an ideology. If its managed by and led by few, you know, unless something is done, im afraid this is really going to be most dangerous. The key to the solution lies in good, honest, responsive government. One that responds to the needs of people. Good governance is really key antidote to this. Its not a luxury. Something thats absolutely essential. Let me ask a quick question and quick answer, then i want to turn to steve hadley to start the audience with the first question. I want to pick up on what you just said. Tom friedman in april 2013 when you resigned wrote that it was an arab spring before there was an arab spring. He described you as a new generation of decent arab or what was needed was a new generation of decent arab leaders, whose primary focus would be the development, their own people, not the enrichment of tribe, sector, party. And part of the difficulty and failure of the arab spring was noncorrupt, that there was not enough support and the arabs, u. S. , israelis for noncorrupt institutionfocused leadership. Do you agree, has the arab spring failed and are these the reasons why the arab spring has failed . Id like to still believe its a nature of a work in progress, although its hard to use those words to describe the state of play when youre looking at the extent of violence and extremism that has taken place and continues to take place. Nevertheless, you know, from time to time, i think its really important to try to take a step or two away from what you see, to put it in perspective. I think its useful to look at the experience of other nations and other revolutions, going back not that far back in history, recently, and see if things like this happened before elsewhere before we would come to the conclusion that, you know, things are impossible in the region. That somehow, you know, arabs are or belong to a species that cannot handle both democracy and stability at the same time. Somehow you need to choose, you know, either democracy or stability. Thats the wrong conclusion. Were like everyone else. We can handle democracy and we need stability. Democracy sustains stability. You cant achieve stability on the strength of force, but you cannot sustain it with a strength of force of governance. Thats what we are missing. Thats whats really important to keep in mind. Looking at history of this, the arab spring is the nature of a revolution. People standing up for their citizens right, for being respected, listened to, taken seriously, if you will. Not thinking that the most important task in life the largest of the leadership and that sort of thing. Arab spring, its essence was about this. Its essence was about this. And i think in that sense, it was overdue. You know, it took a long time. Deep sense of injustice, you know, thinking that there was too much double standards in the way the world was managed, the region itself was managed. The way the global west was relating to the region. The arabs were siding with regimes that were not doing the right thing for their own people. Only they would present the case for them was the case against the alternative, with the alternative first being communism and then muslim brotherhood. This is what you get. You get a region thats unhappy, and so therefore in that sense, it was overdue. But it happened. Its in the nature of the revolution. What else are you going to really tell me that experienced a revolution that delivered stability immediately afterwards. It did not happen even in this country. I found the french revolution, it took three of those. It didnt happen in the chinese refuse solution, the russian revolution. And so yes, the extent of the violence is important. Theres no question about that. But to think that somehow the arab spring, if it is really about a revolution, i think it is fundamentally, to expect, you know, to deliver, serenity, stability, tranquility in the aftermath of a major upheaval like this is expecting too much. Two things. Number one. We need to place it in that kind of perspective to get a better handle on it. But i think its really time for everyone to begin to think that this is a region like all other regions. These are people like all other people. People are people. And stand and have to be laid out for systems of governance that respect their own citizens. This is so basic, but its basically obvious, but somehow you often and then they think they need to find a solution immediately. Youre not going to get there unless they respect them. Thats it in a nutshell. Fascinating answer. Thank you so much, doctor. Steve hadley. I have to make a disclosure that i had the opportunity to have lunch with salam fayyad, and id like to invite you to share a little bit of that conversation, and i realize there are some sensitive pieces to it. The reason i say that is because i think theres a lot of despair in the United States that the Current Situation in gaza can lead anywhere positive. And i think its useful if you could share some thoughts about that both to give some hope but also to stimulate some thinking. And im thinking specifically some comments you made about the kind of ceasefire that might allow both what the israelis want, which is the demilitarization of hamas and what might allow hamas to get what it wants, which is the opening of the borders for flows of goods and services. You talked a little bit about that. What kind of arrangement might permit that. The role that the p. A. Might play in that. And also, the issue of reconstruction of gaza and how that might be structured in such a way that actually could begin not just a reconstruction process but a reform process that could begin to do what you talked about, getting these institutions in a line between gaza and the west bank. I admit these are sensitive questions. I think what you said was very interesting and would be useful, and i would just simply invite you to share that portions that youre comfortable with. Thank you very much. No, i would be extensive on those issues. I think its really important to place this in the right context in terms of how to deal with gaza and to begin to bring that into this course. As i said in my opening remarks, its hard to use thinking in a time of crisis. But in this particular case, i think bringing that forward may help in facilitating an agreement on a ceasefire. People really start to get a sense of what happened afterwards. Understanding divergence. Take, for example, what you said about demilitarization of gaza. Id said that would be a tall order now. Gaza was not demilitarized even when the israeli army was there. Minus the rockets, there was just about everything else. Including the tunnels. Including the tunnels. This is the reality. So for someone to come and say hamas and gaza should be demilitarized as a condition for ceasefire, that really is setting the bar too high. No agreement for ceasefire is possible. Death, injury, misery, epidemics as a consequence, water and the power plant having been bombed and water stations and the rest of it is simply beyond and there is, you know, on the palestinian side, the legitimate demand and expectation for lifting the siege on gaza. One really needs to separate issues here. Its a key point. There was a lot of focus on rafa. I think its important to really take rafa out of the discussion in terms of not completely out of the discussion but not to make the debate on access exclusively one of what to do about rafa. Its now an issue of egypt and palestine. I think all along the idea i mean, post 2007. But since then, after 2007, it became exclusively a palestinian egyptian issue. I think its important. But even before and i think really sadly didnt happen, it should have happened before. You know, nobody really needs to get to an escalation like this. It should have been dealt with before. And discussion between palestinians and egyptians. And the solution to it, even at time of separation, would have been to open it subject to it being run by the palestinian authority. Something that really made sense, even at time of separation. It would have brought the p. A. Back into gaza for the First Time Since june 2007. Important. Something to build on. It could have paved the way for the government afterwards. But to begin with that something basic. Something as basic as that, didnt happen. It should be approached this way. It should not mask the need for resolution, of access issues elsewhere. For sure. But from our point of view as palestinians, opening gaza northward, connecting it with the best bank, is strategically a lot more important. It should be open. Subject matter. Focus on rafa and pushing gaza southward, if you will. Or peace in the region, a twostate solution concept. Something that requires immediate attention. It didnt happen before. It should not be something about ceasefire or no ceasefire. Ceasefire is absolutely necessary. And that discussion needs to begin. You know, egypt needs to say, you know, in order for my National Security interests to be protected, the following arrangement should be respected. And i think palestinians would be more than willing to accommodate. The statelike structure of the palestinian side. And now that there is unity even though its not deep enough and has not taken hold. Regardless of what happens elsewhere. But then again, at this moment, what can happen to immediately change the landscape . History tells us that it takes time. You need to really secure the ceasefire. But you need to give people a sense of what is going to come later. Short of demilitarization. And again, if you could everything, youd have everything. This is natural. This is what economics is about, after all. But you have to make choices. Here is a proposition. You look at a situation where youre the state of israel demanding demilitarization. I dont think thats really realistic. I dont think its really in the cards. Again, they were not able to achieve this even when they were in gaza itself. Lets face it. What kind of nonsense is this . That doesnt work. But short of that, what if there was serious consideration of a promise of a period of calm, calm, total commitment, by consensus, by everybody on the palestinian side. Not the ultimate objective. We surely look forward to the state of palestine to be one that is based on coexistence and total respect for agreements and renouncing violence and to assume nonbelligerence. Including state of israel. But in the runup to that. What if we can, what if we can what if we say a long time with this in my pocket what if we could commit everybody on the thats not demilitarization. Its better than the existing situation. We need to really look at the situation. Unfortunately, its not a choice between good and bad. Its a choice between better and worse. In this particular case, number one, the ceasefire. Two, the promise of people. Thats better than not having anything. S short of what we would like to see happen. But it gets things going. Short see happen. But it gets things going. It requires a greater role for the palestinian authority. Not of the crime thats happened postunification which has not happened. Its for ballistic, if you will, so far. What we really need is one that is inclusive. One that is seriously supported by the factions but one that can gain strength and presence possibly in a way that could make it an effective player. And remember, that was part of the thinking early on in terms of what the Palestinian Government was supposed to do, going back to the road map and inpower person of government. This is not a small issue. This is something that gives all four people to be included. And i prefer personally for it to be inclusive of factions itself. This is a time of national crisis. To be honest with you, but doesnt require commitment. To give everybody the time to unify, but at the same time to agree with israel and for a date certain on ending we cant really push on the domestic front with the International Front. Something like this i think would be necessary. Thank you, doctor. Jane harman. Thank you very much. Its a pleasure to see a dear friend in washington. Thank you. Really a pleasure. Congratulations to the Atlantic Council for this enormous cow in getting our friend to join you. Two things. First of all, everyone in this audience wishes you were still Prime Minister of the palestinian authority. I speak on behalf of everybody here. And dissenting voices, please be silent. Uhhuh. And we all remembered the twoyear plan you produced to improve the authority of palestine if that were still here. That is what my questions about. The p. A. Have done a good job running the west bank. Ramallah is successful and parts of the west bank, not withstanding efforts to build settlements and other things that israel has done that are viewed in a devisive way. Is there a fact that given the arab neighborhood is not fond of hamas to use that story with their support to help build a coalition for enhancing the pas role. Something youve just suggested. As part of the solution which would include a ceasefire, which would include an agreement for i would hope demilitarization of gaza. I understand thats a hard thing to do. But also an agreement for a version of a Marshall Plan to rebuild gaza and run gaza as part of as part of the Demonstration Program and hopefully in the state of palestine. Can more be done leveraging the views of the neighborhood about hamas to give the p. A. The role it has really earned in light of its governance of the west bank . I dont think really, unfortunately, i dont think its either or. First of all we say ceasefire. Ceasefire by whom . Agreement by whom . Mainly hamas. But theyre the ones calling the shots. On the palestinian side. On the palestinian side, who is really actually committing to this . And when you take that into account, and the fact theyve got to be there, its difficult situation for me to watch doesnt have the formal presence in gaza, and that has been the case since 2007. Without, you know, putting together an arrangement that is open to being more inclusive, being able to somehow act only as an agent for reconstruction while growing these other components. Again, i think its really a question of choosing a realistic path to achieving that. What the process of reconstruction at some point will do . What, you know, governance, framework. If right policies are adopted, procedures followed and something that made accepts to people. In terms of shaping views. This is most interesting area for consideration. One needs to be patient. And two, up with needs to keep into account that there are elections. I havent said anything about the election so far, but its important. Moving toward having a democratic state. Militant strong, progressive, shared values of open tolerance and open communication, what have you. We need to rebuild our political process. We need to have elections. Not immediately. Its impossible to do. As this process moves on and the system begins to be opened up for more participation, grow the base of participation, opening it up and then have elections at the point you know, if that happens, i think that is something thats a lot easier. Given where we are, we need to somehow find a way. We need to improvise and find a way as a bridge between now and then. It seems very difficult to conceive of a situation. We are going to dislodge those in the drivers seat and say, give rightofway. Time for someone else to handle this. Excuse me, but we have the ones on the front lines. What are you talking about . You have money or no money . This is part of the discourse we have to be sensitive to. How to really approach this. Think seriously about putting something that could enjoy Critical Mass of support, adequate, just enough to enable it to begin to deliver, rebuild and implement policies that do all of these things and open the system, political system and then have elections. What they produce, they produce. Thank you very much. Questions, please. Good afternoon, sir. 22 years ago i was the staff author of a law that requires the state department to report on the rights of Indigenous Peoples around the world and its annual human rights reports. In terms of, there is no report. And if you use the term indigineity as used by the United Nations, it would both force israels neighbors to recognize israel as being indigenous to the area, as well as require israel to recognize the palestines as having a right to their homeland. In other words, a nation state that is viable. Why isnt the question of indigineity part of the new paradigms that need to be discussed in the future once the bloodshed dies down . You know, ive argued for something less than that. Among other things, you know, going back to 1993, socalled declaration of mutual recognition. When the plo acting once again on behalf of all palestinians. Recognized the right, this is language. Specific language. The right of the state of israel to exist in peace and security. Thats what has not happened. What did not happen then and has not happened since was for there to be a mission by israeli of our right, palestinians right, to an independent state. That, i think, should be adequate to really put the process on a more symmetrical path going forward. And that in some way begins to address the deep sense of security and sense of impossibility and outright disillusionment that is so prevalent on the palestinian side. When they see the expansion of settlements and what all that is doing. The heavy weight of the settlements in terms of the prospects of twostate solution. You have a formal recognition of our right. Is this too much to ask for . After all they did recognize the right of the state of israel to exist as a state in 1993. Contrary to the name of it, decoration of mutual recognition, the recognition did not happen. Actually, for much of the period, much of the period since 1996, the platform of the front parties were to say they were not very friendly to the resolution. So it is important for there to be that recognition. I believe in that. I would not take it beyond that. Thats the basic requirement. I wouldnt take it to the next lev level. Just make sure it is adequate and move on. Fred hoff, senior fellow here. You may want to add the role you played in the peace issues. Thank you. Dr. Fayyad, you mentioned a possibly creative way forward in all of this in terms of negotiations would be to set a date certain by which the occupation would come to an end. Correct. Could you expand on what that actually means in terms of procedure, and what would it look like when that date is arrived at . I think it is necessary. Oslo, by the way and not many people know this, oslos attempt was curiously silent on the issue of palestinian sovereignty and statehood. It is presumed, was presumed when oslo agreed that this is what the outcome was going to be, but you are not going to find any reference to palestinian state and sovereignty in the oslo communication. Its very strange. The understanding is exactly the opposite. I think, again, that may have made sense given the history and given the difficulty involved in getting people together to sign on to something. I would not take away anything from the huge significance of the signing on the white house lawn september 1993. I know many people were there personally and moved the world by that scene. It was very significant. Maybe at the time, to be fair to those engaged in it, maybe at the time the thinking was that this was going to be about the maximum of five years and it was going to happen, maybe justifies having gotten into it, but there is no justification for continuing to go on with it without an adjustment that would create the presumption of occurrence of that which we palestinians most desperately would like to see happen, which i argue is of equally importance to the israelis. Because peace and security in the region really requires that, to be honest with you. When you are looking at a situation where that is missing, all of a sudden the framework is flawed. There are other cases where occupation or the way hong kong was turned over to china, it was supposed to happen within a certain time period in 1997. Time work. There was a lot of discussion and negotiation leading up to that. Negotiations should be about arrangements. They should be about assurances, but they should not be about principles. We should no longer, 20 years past oslo be talking about whether or not palestinians do have an alienable right to live at free people with dignity in their country as an expression of their natural right to the exercise of their rights. We shouldnt be discussing this. We should be behind this. Thats whats missing. I think with the end having come to an end, we need to define this. Lets talk about one that is feasible. This is not to preempt negotiations. Vietnam did not preempt with china. There is a certainty of it. Negotiate on arrangements, assurances, a solution out there that is enough in the body of International Law as it exists, various solutions of the United Nations that provide guidance can agree on the assurances and arrangements that underpin it. Thats what it is. Then we cant approach it in the way things are happening right now. This is in the framework right now. Without presumption of an end to occupation that is enshrined in a binding agreement, with this framework with palestinians, go negotiate with israel for however long it takes, and so long as you do not take what is an offer, you have to accept the reality of continuing occupation, oppressive occupation. There is something wrong with this. That is what i am saying needs to be fixed. Everybody needs to be assured about this. Send in the palestinians. Demilitarization was mentioned. Period of calm. Empowering the palestinian authority, empowering the plo, can you imagine what it would do to the capacity of the p. A. To begin to look productive again, if it is able to go to the Palestinian People today and say, we do have a commitment, binding commitment, enshrined in the United Nations Security Council solution. This is one trip to new york i would like to take. Like to take. That provides for ending the occupation. That would immediately begin to give people a sense of hope. Negotiate . Yes, we do negotiate. But theres no illusion as to what the outcome is. The outcome cannot be continued occupation. What is the incentive . When you look at the framework and the huge imbalance, listen to what is said by cabinet officer after cabinet officer on the israeli side about Palestinian Statehood and a twostate solution, including words by Prime Minister netanyahu himself recently, who said something to the effect that he was right all along. That he wanted people to know he was israeli people to be right, to know he was right all along about there not being a possibility of israel relinquishing control over territories west over jordan. What does that do to the twostate solution . So there is that rhetoric out there. And its significant. What do you do to provide assurance . What do you do to really get israelis themselves to believe this is something they really have to contend with. Its not a matter of choice. You know, there is the question of a people that are living under oppressive ourpccupation, which it does not want. I think its time for everybody to grow up and to approach it sensibly but to ensure that as we move forward theyre able to bring people along, to carry, in other words. Thank you, doctor. Im going to ask you a final question. Weve run out of time. Its off twitter from Julian Henson in paris. With gaza in ruins and the west bank economically ailing, could Economic Development hold the key to solution of the conflict . Ill also put it a different way. You predicted when you were Prime Minister that wed have a palestinian state by 2011. A lot of your approaches, what people called unilateralism at the time, which was you were less interested in the symbolism of recognition of a palestinian state of the u. N. And more interested of what could get done on the ground. So take that question but also lay on to this when do you now predict there be a palestinian state, and what would you do unilaterally right now in the palestinian position to push this along . That was constructive unilateralism as opposed to Something Else called settlement activity and the rest of it. I did not predict, actually, at the time that would happen in two years. What the program was about specifically, it was inspired and motivated by political thinking. What i predicted and said were going to be ready for was statehood. The program was about, you know, sending a signal to everyone. Similar to what ive been saying today in a way. Putting everyone on notice. That we olympians expect to be ready for statehood in two years. That was meant to say, if we are successful and somehow, you know, become ready for statehood, in the sense of being able to govern ourselves effectively and handle obligations responsibly and seen there way by the International Community and therefore effectively answering questions that were really put forward in 2001, 2002, 2003. If we were to be able to do this and reduce this whole issue of occupation, period. Not occupation, but the idea was that this was going to be Strong Enough to bring about the transformation necessary to secure a solution. So what the program was about was about inspiring ourselves to get ready for statehood in two years and telling people beforehand. The idea was not to pass a test and say, we took a test and passed it without announcement. But to actually say, you know, go out and say this is what we did in august 2009. Two years, we expect to be ready for statehood. That was the idea. Instead of saying, unless occupation ends in two years, were going to turn the tables. We essentially said the same thing in a good way. Were going to be ready for a state. Are we going to be ready . Are we going to do the necessary heavy lifting needed to bring the occupation to an end . In a technical sense, we succeeded. Year and a half into this, we got that recognition. Recognition of the reality. People gave us a birth certificate of the reality of the statehood. April was a significant date. Year and a half into the implementation of that program we got testimonials by Relevant International Financial Institutions and the united natio nations saying something to the effect that palestinians had crossed the threshold of readiness for statehood in the form of competence, strong institutions of state capable of delivering standards. It was really significant. Its too bad that did not really generate the transformation necessary on the political side. That process of transformation is needed. In order to bridge that gap of expectations between the maximum offer by israel and the minimum acceptable to us, that state of palestine needs to be allowed to evolve, to emerge. Its not going to really happen to anybody or for anybody. Its going to be in the interest of everyone. It certainly would be for full embodiment. Palestinians have been so desperate to live with dignity and freedom of country. Thats really what this is fundamentally about. And that is something that requires preparation and building and through it some serious transformation. Thats what this is about. Doctor, there are is many more questions in the audience. Im sorry we havent got time to get to them. Let me close by saying just a couple things. First of all, the text of his full statement will be available out in the foyer and also online at atlanticcouncil. Org. Second seconda secondarily, let me quote tom friedman. He essentially said to the palestinians, had messages to various people from in his excellent column that people may want to look at. But he said, if theres no place quote, if theres no place for a solid fayam type, an independent palestine will forever elude you. I think weve heard today in these comments why tom wrote that. I think a lot of us in this room may agree with that. Thank you so much for your service. Thank you for joining the Atlantic Council. Were delighted well be able to work with you. Best of luck to you, your people, and the region. Thank you. Thank you. [ applause ] american artifacts on American History tv. This weekend our visit to the National Security archives at George Washington university reveals declassified governments about the gulf of tonkin in vietnam. 50 years ago the gulf of tonkin resolution was passed giving president johnson the power to wage war. American artifactartifacts, sun 6 00 p. M. Eastern. While congress is in recess, American History tv will be in primetime monday through friday at 8 00 p. M. Eastern, featuring events from watergate on its 40th anniversary. American history tv, on cspan3. Author Sylvia Morris is our guest on this weeks q a. She was to beautiful and so smart and also so witty that she became she was just always irresistible to men. I never saw even in her old age i gave her 80th birthday party. Richard cohen, the washington columnist, was at this party. They sat together after dinner having coffee. At one point she began to stroke his beard. Afterwards he said, heavens, he said, ive never met an 80yearold before that i wanted to leap into bed with. She had this vampish quality, a seductive quality her entire life. On the life and career of claire booth lewis, and sharing about their personal relationship during her final years. Sunday night at 8 00 eastern and pacific on cspans qq a. Were live this afternoon on capitol hill where theres about to be a discussion on Prison Health. Its hosted by the alliance for health reform. Panelists will examine challenges in delivering health care to the growing number of inmates. We expect to hear from former inmates and Prison Health officials. Its expected to begin any moment here. Live coverage on cspan3. Your attention, please. I dont want to interrupt your lunch munching, but id like to get us started, if we could. We have a lot of ground to cover and some great people to hear from. I know im looking forward to that. My name is ed howard. Im with the alliance for health reform, and i want to welcome you to this program on behalf of senator rockefeller, senator blunt, our board of directors. The program concerns the health of people in prisons and other correctional facilities and the health care they need and the health care they receive, which may be the same and may not be the same. If youre concerned about getting proper care to those who need it, then how those behind bars have access to care should be important to you. And if you care about state budgets, you need to care about Prison Health. States spent about 8 billion on Correctional Health care in 2011, which was about 1 in six of their entire correctional budget. That level of spending shouldnt be surprising. This is not a healthy population. It includes a lot of folks with chronic conditions, with Mental Illness, with addiction disorders, and its getting older as the population ages. So its not surprising that states are trying a whole range of different strategies to get a handle on Correctional Health spending. Everything from contracting with third parties to deliver the care to having more services delivered on site, to taking advantage of new Health Coverage opportunities for inmates. So today were going to take a look at how well those strategies and some others are working and what kinds of policy changes might be helpful to improve both the quality and the value of the care that this population receives. And as we examine these issues, were pleased to have as a partner in todays program. Later in the program, youll hear from dr. Asher, whos a physician from a tennessee joint venture that provides Correctional Health care and in which theyre a partner. Let me do a little housekeeping before we get started. If you want to tweet, thats how you do it, with the hash tag prisonhealth. If you need wifi in order to tweet or do anything else, the credentials are on the screen. Feel free to make use of them. Theres a bunch of good material in the packets you received when you came in, includining b biographical information. Theres a materials list and additional material you can go to for further edification. All of that is on our website, allhealth. Org. Particularly that one pager you should try online because you can click on those things and you dont have to worry about copying a long url. Theres going to be a video recording available of this briefing in a couple of days on our website followed by a transcript a day or two after that. And you can follow along with the slides that the speakers will be using today on that website. If youre watching on cspan, you can find all these materials and the slides on our website. You can follow along if that is what you would like to do. Word about questions at the appropriate time, you can ask a question three ways. Theres a green card you can fill out and hold up. There are microphones at either side of the room you can use to ask in your own voice. And you can tweet us a question using the hash tag, and well monitor and get that up to the dais. The only other thing i would ask is as we go forward, that you fill out the blue evaluation form thats in your packet so we can improve these programs as we go along and cover subjects and have speakers that would be of the most interest to you. To lets get to the program. Our format is a little different than usual. There are going to be two panels, not just one. Youll have a chance to ask questions after each one. First were going to get an overview of the issue and then turn to a view of these issues from some people who understand them from firsthand experience. And then a second panel will address concerns about health care and the correctional system from the standpoint of some folks who are charged with delivering that care. So starting with our first panel. Ill introduce them all to keep the continuity of the conversation going. Were going to start with Steve Rosenberg, whos the president and founder of Community Oriented Correctional Health services. Is there a pronounceable acronym . Cochs. Those of you who watch the redskins tryout understand coaches are important. Steves been working to assure Health Care Access to vulnerable populations for more than 40 years and provides Technical Assistance to correctional systems toward that end. Debra rowe is the executive director of returning Citizens United here in d. C. With 20plus Years Experience supporting and advocating for those reentering from incarceration. She holds a masters degree in Human Services and spent several years incarcerated herself some years ago. Finally, well hear from jacqueline craigbey, whos a supervisor at a Domestic Violence safe house here in town and an advocate for inmates and former inmates among other vulnerable groups. Hes the first paralegal hired by the university of d. C. Law school, and before she, quote, turned her life around, unquote, as she phrases it, she spent more than 20 years in prison herself. So were really looking forward to hearing from you folks, and well turn first to Steve Rosenberg. Well, thanks, ed. Thank you, all. Welcome for joining us. Im really appreciative to have the opportunity to talk about this relationship between Public Health and Public Safety because theyre so closely tied. As ed mentioned, im president of cochs. Our goal is to break down the barriers and build connectivity between our Public Health and Public Safety systems. Before proceeding, i just want to make a quick distinction between jails and prisons to make sure everybody understands what were talking about. Jails are county or citybased places where folks are held prior to trial or for being sentenced to a misdemeanor usually less than one year. Prisons are operated by state or federal governments, and folks go there for a longer sentence. With the data you have in front of you, shows the point in time snapshot of whos in jail and whos in prison, but id like to turn your attention to the data below that, which is that more than 11 million folks annually circulate through our nations jails. Those folks are there for a very brief time, and 4 of them, only 4 of them end up in state prison. 96 are released directly from jail back into the community. So when we look whos cycling in and out of jails, what we see are these are our nations most marginalized folks. Theyre largely young, largely nonwhite, largely poor, and suffering from diseases way in pro proportion to it the rest of the population. Let me just give you some data you can see that. These are the rates of hepatitis for justiceinvolved individuals compared to nonjusticeinvolved individuals. And you can see as we get older down the age spectrum, the gap widens largely. This is the data on hiv compared to justiceinvolved individuals compared to nonjusticeinvolved individuals. This is the data on Substance Use disorder. There was a recent study that was completed. Its known as the adam study, which looked at the incidence of Substance Abuse disorders. So we obviously can see that much of our criminal Justice System is inherently a Public Health challenge. Folks have Substance Use disorder. Its that disorder thats having them end up in the correctional system. Similarly, folks with serious Mental Illness look at that data. National population compared to local population. And for women in particular, this is a much greater challenge. More than 30 of women who have incarceration or justiceinvolved have a serious Mental Illness. Obviously what were depicting to you is this is a challenging population. But what i want to show you are their insurance status. Prior to january 1st, 2014, 90 of individuals leaving jail were uninsured. So we make this investment in stabilizing their health care because we are required to under the Supreme Courts ruling which said that public jurisdictions have a responsibility under the eighth amendment to not be deliberately indifferent to the citizens that are under their charge. So we make this investment in stabilizing them and then the minute they leave the street, typically we lose that investment. But its the bottom point i think should be of more concern to all of us. A study showed that of individuals incarcerated who had a chronic disease, 80 of them did not receive treatment for that chronic disease in the year prior to their arrest. So if you have an untreated Behavioral Health disorder, youre not receiving treatment for that disorder in the community. The likelihood of your ending up exposed to the criminal Justice System becomes fairly high. So what do we know about what happens when we treat the underlying Substance Use disorder . Washington state in 2003 ran a Natural Science experiment. Their data system allows them to organize the jail booking data, medicaid claims data, and Mental Health utilization data. The state provided 30 million of general funds to its five largest counties for them to go ahead and treat as they saw fit individuals with Substance Use disorder. And the results were startling. Notice this is not completion of Substance Abuse treatment. This is exposure to Substance Abuse treatment. The first thing you want to notice is the arrest rate went down by 33 . Simply by exposing folks to treatment, the arrest rate went down by a third. For every dollar that the state spent on treating folks with Substance Use disorder, it saved a hard 1. 16 in criminal justice costs. If the cost of victims of crime are included, the savings was 2. 87 for every dollar saved. Thats on the justice side. Now lets look on the health care side. As youve seen, folks with Justice Experience have very high morbidity. Prior to 2003, their Health Care Costs were increasing at a rate of 5. 5 annually. Once they were exposed to Substance Abuse disorder treatment, all of the sudden their costs dropped to 2. 2 annually. Here in d. C. , folks are always talking about bending the cost curve. What you have in front of you is a perfect example of a cost curve that was bent simply by providing access to Substance Abuse disorder treatment. Bent out of shape. Thats right. Bent way out of shape. Where that leaves us are recommendations for you as policymakers in going forward. I really want to give you four things to consider. One is, these are folks who are not mothers with kids with ear aches who are going to bang on the door of the welfare system say, give me a medicaid card. A study in 2009 in massachusetts showed while there are only 3 of individuals in the state uninsured, 22 of individuals showing up at publicly funded Substance Abuse treatment programs whose demographic parallel is exactly that of justiceinvolved individuals, largely male, largely poor, those folks had an uninsurance rate of 22 . So the very first thing i want to make sure you all understand is that targeted outreach for enrollment will be necessary. This is going to be a complex and difficult population to enroll. And that the use of the medicaid Administrative Claiming Program by Public Safety entities can facilitate their enrollment. Most folks within the Public Safety world know nothing about the medicaid Administrative Claiming Program, and that is a great opportunity for use for states and localities to bring in resources to enable them to enroll this challenging population, and as you just saw, enrolling this population will save everyone funds. The second is that we need to understand the relationship between Substance Use disorders and the criminal Justice System and how Health Care Providers both in the corrections and in the community can Work Together to increase Public Safety. Thats the second take home. The third take home is wanting to talk a little bit about how its important that we understand that we have an our books going back to the Medicaid Program this thing called the imd exclusion, or that is people who are patients in an institution of mental disease cannot receive medicaid. The purpose of that goes back to the desire when medicaid was started to not have the state hospitals suddenly become financed by the federal government. Well, our science and vocabulary have advanced since then. We now understand things like th thraumatic brain injury. I want to urge you to give very careful consideration as policymakers to make sure that statutory folks that are 50 years old that may not be relevant in todays world, that we dont fail to meet this juncture of Public Health and Public Safety because were trapped in old statutory and regulatory language and we figure out how to change that world in order to really facilitate the opportunities. And i guess my last recommendation would be to make sure that we Pay Attention to how we build bridges. We have these two separate silos. We have a criminal justice silo over here. We have a Community Health silo over there. These silos have not been very good at talking with one another, at informing one another. I guess the third would be that here in d. C. On a policy level, that we do everything that we can to bridge those gaps and to make sure that folks understand that Public Health and Public Safety are incredibly intertwined. With that, ed, ill go to the folks to your right. Terrific. Thanks very much, steve. Could i just ask you one question . Sure. You were talking about new terms. Ill tell you one new term i would appreciate your defining. That is criminogenic. Sure. What we now know is we now have identified the causes of behavior that result in people gaving in a criminal justice manner, the people becoming justice involved. Those come under the general heading of criminogenic. That means the characteristics that have way more to do with Mental Health, housing, lifestyle, anger management, they have to do with peer relationships, that theres this whole bevy that we know now how to treat. The challenge has been the Regulatory Framework in a postAffordable Care act world that limits our treatment. I want to make it clear that this is a bipartisan issue. Governor perry, governor deal of georgia, theyve been going out and promoting treatment of criminogen criminogenic behavior rather than incarceration. What changes is states who have enrolled in the Affordable Care act is to scale this at a level a state governor cannot necessarily do. Thank you very much. Well turn next to debra rowe. Thank you, ed. All right. Good afternoon. During my incarceration at the reformatory in the late 1980s, i witnessed the disheartening maltreatment of who were ill and resided in my dorm. For example, the women who were sick were kept at the very end of the dorm. This was during the time when hiv and a. I. D. S. Became prevalent in communities can and several of the women that i am referencing had hiv infections. During that period, i met my colleague here, jacqueline. You see, we along with a few other sisters were the voice for those women. We raised cane and forced Correctional Officers to get off of their behind and get them to the infirmary when needed. And we bathed and fed them ourselves. Upon release, i was offered a job by the d. C. Department of Corrections Health administration to educate my inmate and reentry peers about hiv disease. While studying for my job, i read a report from the centers for Disease Control that stated that 16 of those entering d. C. Jail had hiv infection. And i wondered, how did they know that . I began my personal inquiry because i knew that hiv testing was not being offered at that time. Im going to venture out and say that they were blind testing these inmates, and after advocating for testing in the jail, the correctional medical staff was frantic that they didnt have the resources for the testing, which confirmed my suspicion about the blind test. I see the same parallel with hepatitis c and that many, many women, some of whom have served ten years or less, who have had blood draws have contracted hep c infections and were unaware of their status until they came home and visited a Free Community Physicians Office and learned of their results from a laboratory result there. One inmate who has served 15 years in prison went from lewisberg to cumberland, then to petersburg and then to petersburg camp and had blood draws upon entry to each of those institutions. Yet, he did not learn of his hep c diagnosis until he was tested at a Community Clinic upon his release. According to the center for Disease Control, the prevalence of hep c infection in Prison Inmates is substantially higher than that of the u. S. General population. Among Prison Inmates, 16 to 41 have ever been infected with hep c and 12 to 35 are chronically infected compared to 1. 5 in uninstitutionalized u. S. Population. Its primarily associated with a history of injection drug use. Cdc recommends that correctional facilities ask inmates questions about their risk factors for hc infection during their entry medical evaluations. Inmates reporting risk factors should be tested, and those who test positive should receive further medical evaluation to determine if they have chronic infection and or liver disease. Although its not exclusively considered a sexually transmitted disease, the hep c virus has the potential to be spread through sexual contact. It shouldnt matter that they are incarcerated. They have the right to know. All of this is happening in the private prisons. In closing, the inmates have reported that their Health Services are limited, and theyre being charged. They have to pay 5 to sign up for a sick call and medications, and you can pay and sign up to see a dentist, for example, and may not see him until the following year. One inmate told me a few days ago that he had an abscess that swelled up to the size of a baseball. After three weeks before he was treated. Im passionately concerned about those who are 55 and older in the system. This concludes my story, and im happy to answer any questions. And i do concur with all of steve rosen burgs recommendations. Thank you. Thank you very much, debra. And of course, for those of you who havent been Reading Health policy stories for the last year or so, hep c at 1,000 a pill has a cure. Prison systems and other correctional facilities right now are having to figure out how to deal with the kinds of percentages and the numbers of inmates and residents that debra was talking about. So Public Health meets Public Safety. Correctional policy. You bet. Now well turn to jacqueline craigbey. Thank you so much for being here. Thank you for having me. Excuse me. My name is jacqueline craigbey. I am a former inmate. I have several stories from when i was incarcerated as it relates to the medical in prison. While i was there, i broke my leg, and it took them approximately a week before they got me to the hospital. I was taken to the infirmary there in the jail, and they put a makeshift cast on. I mean, it was just put on with no padding, no anything. I dont even know if the lady had a license to put this thing on me. When i finally got to the hospital a week later, the doctors over there laughed about it and called one another and come and see this funny thing that was on my foot. The medical facility just didnt a place where inmates should be. Nobody there is actually looking to take care of an inmate. Its just a job to them. Theyre just there for the paycheck. When i was pregnant, i had a child while i was incarcerated. And after i had my child, you know, women here know that you have to have a sixweek checkup after having a child. Well, i saw the doctor in the hallway. He just touched my stomach and said, oh, youre fine, and that was my sixweek checkup. And these are the type of things that go on in the prison and are not talked about. Nobody talks about the people who have hiv, and theyre afraid for other people to know that they have hiv, so they dont go to the medical facility to get their medications. They dont want people to know their status. So these are people who are sitting there with this disease and not being treated. They dont have the staff to talk to these women and men, to let them know its okay to come to the infirmary or some kind of way to give them this medicine without everybody knowing what the medicine is. Because when you go to the line, Everybody Knows what everybodys taking. So some people dont want to take their medication. And thats a problem. Thats a big problem. There should be some kind of way where women or men can get their medication without the world knowing what youre taking. Also, ive seen people pass die in prison for things that could have been prevented. Women were coming down with cancer in connecticut, and it was just crazy. It was so many women at one time coming up with these cancer diagnoses. Before they would take them to a facility to be treated, they would sit them there and talk about all these different tests, and had they taken them to a facility to be treated before doing all these different tests and sitting them there waiting around, they could have been treated and would have been fine probably. But instead, they sat there and waited and waited and waited, and these women died in prison. When they got there, nobody said that they had cancer or anything. So they were not tested for these things. But yet, they had these different ailments and nobody in prison cared. Nobody cares what goes on with an inmate. They consider us the forgotten, the ones that nobody cares about. So we have to care for one another. So i would call attorneys and people that i knew in the district and have them fly to connecticut to help one of the sisters or brothers that needed some help, because otherwise well sit there and languish in prison with no help at all. And its just a really sad thing for us to languish away like that. And thats all i have to say today. Thats quite a lot to have to say. Thank you, jacqueline. Let me just ask both of you youve described some conditions that would result in the issuance of some arrest warrants if they occurred in some other situations. And i wonder what your perception is of the progress that is being made in the facilities you know about toward addressing some of these shortcomings. There is no progress being made. People are still jackie was in how many years ago in connecticut . 2001. Okay, 2001. Women and men are still dying, and Family Members i receive calls from Family Members that they were just notified that their Family Member died and they buried them. Or they died, and they cant give you any answers. Are you going to be able to make accommodations for your loved one or not . You know, its just pointblank like that. Theyre still dying. All of what i just talked about, the young man with the abscess or the people coming home with hepatitis c and not knowing or the people that are in there very ill our women d. C. Gave up the rights to our inmates. We were blessed to be in lauton reformatory during that time. But they closed our local prison. So all of our women are in a medical facility way down in florida. D. C. Residents. Thats another thing. Theyre far away from home, and theyre sick and theyre far away from home. At least if they were in their vicinity and theyre supposed to be in a 500mile radius, but theyre not. Theyre all over the country. Our inmates are spread all over the country. But its not just speaking for our d. C. Inmates. Any inmates. I collaboraslacollaborate with different states on advocacy for reentry. But anywhere, the family contact is very important. Its very important that youre able to have contact with your family, especially if theyre ill. Just like i said, if youre blind testing people and they dont know, just like cancer, if its undiagnosed, then i mean, look at the people that go to the doctor and they tell you, you have six months to live. But that cancer was in your body longer than that. These these are its like theyre just forgotten buzz theyre locked up. You know, when they come home, they have what they call the new federal Second Chance act. Because they deserve a Second Chance. So these longimposed sentences and then youre not going to take care of them. Like i said, you have in oklahoma, you have a lot of elderly geriatric people. A man came home 70something years old. He called my colleague and said hes still on parole. They said i got a job. They said i got to get a job. What is he going to do . That used to be your night watchman or Something Like that. What is he going to do . All we could do was get him some glasses. He didnt get proper treatment for his vision. So my colleague helped him to get glasses. We couldnt help him find work. But still, why hold somebody to 77, 85 and theyre sick. Its very expensive to take care of them. So i know that these reforms and theyre talking about medicaid and all of that now, but theyre going to have to go back and cover a lot of inmates because a lot of our people are suffering in prison. And if you make too much noise about it or your family calls and advocates, you can get put in the hole. And imagine having a toothache and youre in a cell. Because you know you need to pace back and forth. Any pain, you need some type of release. But youre in a cell in agony. In the a cell, not in an infirmary. At least in an infirmary, you can lay down and you can and youre getting seen or anything. A year to see a dentist, a year and youre paying for it now. Youre paying for it. You work, and if your familys not sending you money, then you work in a detail so you have money for commissary. But now you pay 5 for this. Its taken out of your money. Youre paying for your service, but you cant be seen. Its no, theres no progress. There is no progress. Ed . Steve, please. I dont disagree with anything youre saying, but i want to frame it. Traditionally, we send folks out to islands when they need to be incarcerated. Devils island, alcatraz, australia. Parts of the United States early on in our history. Weve always had this approach that folks who were in the Justice System should be isolated and kept separate from folks. In that process of keeping folks separate, the kind of experiences that im hearing you and jackie describe are not uncommon. The blessing is were all in this room in this very Lovely Senate chambers today. Were in this room for this Lovely Senate chambers today because we have this bipartisan opportunity to change that. And we have this bipartisan opportunity to change that because we recognize that keeping folks isolated on an island does not make sense in the 21st century. And that we have to figure out how we build bridges. And those bridges are partially Electronic Medical record bridges, which well be talking about in the second panel. Those bridges are partly thinking differently about how we do sentencing for nonviolent, nonsexual offenders. But the important thing, i think, is the pony in this. Were sitting here in this beautiful room in the senate today because there are several hundred of you who are recognizing that Public Health and Public Safety are intertwined. And managing Public Safety by keeping folks on an island is not the way that we want to go forward. Pretty good frame. We are going to stop at this point and ask if you have questions for any of the panelists who are up here. Let me remind you you can either fill out a card or go to a microphone so everybody else can hear your question. If you are part of the twitter verse, you can use that as a medium to get the question to us as well. Theres another microphone right over here, sir. So i would ask everybody who comes to a microphone to identify themselves and try to keep the question as brief as we can so we can get to the most questions that we can. Im dr. Caroline poplin. Im a primary care physician. We ha i have a quick comment about disability. I worked for Social Security disability for a while in baltimore. Very often we could not get Prison Health records. I mean, we had people who werent in prison who had no records at all. The people who were in prison, we knew they had records, but very often the prisons wouldnt send them and the states wouldnt work terribly hard. That should be something easy, especially with electronic records. Debra . I want to say, we have in the district made progress in that area. I used to facilitate a federal partners meeting. It was u. S. Parole with our medical system here, which is unity health care. Thats where all of our Community Health clinics are. And we sat down and we worked it out where all medical records because even when an inmate leaves the prison, they had trouble getting their record. So now all of the records follow them. They all go to unity. Theyre centrally located in unity. Thats one progress we have made in the district. And a onesentence question. Does the work they do in prison, does that count towards medicare . Social security, medicare. No, it does not. There is a statutory prohibition wow. For medicare paying for any Services Provided behind bars. Thst also a statutory provision that if youre on parole or probation, you cannot receive medicare benefit. On the medicaid side, theres something known as the inmate exception, which goes back again to the original finding of medicaid, which states if youre an inmate of a Public Institution as the exact statutory language, you cannot receive medicaid benefits at all. So again, one of the challenges going back to my comment about islands, and what im hearing you say is we need to figure out creatively how we build bridges to those islands. Obviously, medical records is a part of it. Thinking about bringing standards of care that medicaid brings is another part of it. But at this point, were all very much in the process of understanding it is not in our benefit to maintain those islands and the query becomes how do we build a bridge. Thank you. If i can just i dont know whether this is something that youve had to grapple with, but one of the parts of your question was whether the work that was being done in prison could be counted as a quarter that would give you credit toward medicare credit eventually. And the answer is no. No . Okay. Hi. Yes, sir . Glen field, urban affairs advocate. Debra, i heard you mention a 500mile law. We constantly let this government get away with it. We have a law thats established that any d. C. Court offender or d. C. Inmate couldnt be moved no more than 500 miles just to keep them with your Family Members, your loved ones. People in the District Of Columbia get locked up and have been traumatized. We have Racial Disparity going on here. Any inmate like 3,500 return back into the city. 85 goes back within three years. So you celebrate. Am i right, ms. Rowe . You celebrate you made it past three years because its a revolving door. Im just asking steve and the panel, if you can agree with me, in the prison industrial industry, that they make a profit of this revolving door. When you dont get Proper Health care, as far as Mental Health care, when you have been traumatized, posttraumatic stress disorder, youre coming back to prison. And the private industry makes a lot of money. They dont spend that money on health care, mental or physical. If you came into the prison system in the private industry and your pill cost 1,000 or 30 pills cost 600, youre not going to get that medication. Youre not going to get the treatment you had in another facility or when you were at home. Because 60 of any profits in the prison system as far as private are concerned is medical. A lot of people have been suffering, and theyre going to suffer more. Then theyre allowed to come back out on the street. Ill point it out to steve, you know, mostly that we do need wouldnt you think we need some advocacy and some monitoring mainly at these private prisons and making sure that their discharge plan starts earlier than eight months. Doesnt mean the discharge plan you physically and mentally start getting these people back into health instead of sending them back out on the street, passing on diseases and thinking about new crimes can and things of that nature. Because people take drugs because theyve been traumatized in these prisons. So it creates a criminal. Because theyve been traumati traumatized. They dont know how to deal with these Mental Health illnesses. They have to supply their habit, and theyre coming to get the citizens when they come home because they havent been treated correctly. So you got worse off than what you were before you went in any system. Id like the panel to chime in on any and all of that. Thank you. Id like to answer that question by framing slightly differently. We have proprietary companies that provide Medicaid Services through the United States. But those companies are regulated. Those companies have Performance Measures they need to meet contractually. The challenge with the Correctional Health system is by and large an unregulated industry. And if you have an unregulated industry, you have the opportunity for both the kind of human suffering that we heard debra and jackie describe, and the opportunity, sir, that i just heard you describe. I think, again, thats partly where being in this room in this building points to something we dont allow in any other sector of spending 8 billion on health care. Do we allow it to be unregulated . Do we allow it to operate without standards, without Quality Assurance, without any of the things that are statutorily required . So we now leave that under our federal system. We leave that up to states and counties to go ahead and regulate or not regulate as they may see fit. So what im hearing you describe is an underlying challenge that our federal system has allowed state localities to make their own determinations as to what regulatory or Quality Assurance framework theyre going to put down on Correctional Health. And in many jurisdictions, thats very nominal. Okay. We have two folks at a microphone, and we really need to get to our second panel as well. So i would ask you to ask your question and well try to get it answered as expeditiously as possible. I just want my name is mary tierny. Im a pediatrician. I had the privilege of getting a grant. We did outreach to youngsters coming out of the juvenile Justice System. We got them on medicaid before they were or at least at the time they were discharged. We coached parents. We coached the youth. And the two people that really should be given credit is jane adams in kansas who ran the program and the medicaid director who was full force behind this in dr. Andy ellison, who at the time was the kansas medicaid director. He was magnificent in getting this. The recidivism rate was dropped by 50 , even in the highest risk youth. Im sorry. I dont have a question, but i think its a good model to think about. Thanks, mary. Can i go ahead . Yes, linda. Go right ahead. Linda flowers, aarp Public Policy institute. So in my mind and thank you for this panel. Its just been tremendous and very insightful. Im learning a lot. So it sounds like theres this cause shifting going on between the federal government while theyre in there not paying for the things that people need, and then they get out if theyre in a federal prison. Then theyre in a state responsibility, whether or not theres a Medicaid Expansion or they become disabled or aged and can get on to medicaid that way. So im wondering if you could first, there needs to be more data about the amount of money that is not being spent on one end and how that translates into increakreecreased spending at t level once most of these people get out of prison. I think that could be a powerful tool for states to use to try to leverage better improvements while people are incarcerated in federal penitentiaries. And the other thing is i wonder if you can also try to figure out a way to cut the data by state to sort of show to a state the value of doing the Medicaid Expansion, that youre going to save a lot more money on other unanticipated costs because youve made a way for people to have a pathway to health care. But and also, i wonder if you can talk about any best practices in states working with the federal government and states working together to have a better outcome while people are incarcerated and then when they transition out into a state into states. So i think you can beef this issue up a whole lot more than what im hearing. Linda, those efforts are actually already under way. The federal bureau of prisons has just instigated a requirement for a standardized release in terms of doing Substance Use disorder evaluation. I think were starting to see that kind of process come down. On the Medicaid Expansion side, i think the data that i gave you from Washington State speaks very loudly to how theres a direct relationship between health care spending, recidivism, and criminal justice spending. So i dont think its because of a lack of data that we havent been able to make that push. I think, again, we have to realize that Public Health and Public Safety are intertwined and interconnected, and it does not serve anyones interest let alone the taxpayer to keep folks isolated on an island without the appropriate Regulatory Framework that we come to expect as part of our federal state and local partnership. So what i would say is the data is there, and were in the process of the bop trying to implement exactly the kind of thing youre talking about. What we havent done yet is we havent made this conceptual leap. Thats what were all here today to talk about. We havent made this conceptual leap that says we need to figure out how to build conceptual leap that has to build as many and as sturdy bridges between community and corrections as we can. Okay. Bob, last question. Bob gris with the institute of social medicine and Community Health. I remember when senator wolford ran for senator from pennsylvania and made a big case about prisoners being one with of the only populations in the United States that had a right to health care. In fact, that was based on a Supreme Court decision. How does that precedent not create the political power to implement the kinds of solutions that youre hinting at and havent we learned anything from the tuskegee experiment . It seems like collecting data and not using it is a violation of of our civil rights. So where is that how does that fit into this problem . Where are the lawyers . Right. First, there are several questions and first i have to be a nerd here and correct, its native americans under treaty and incarcerated individuals are the two individuals to whom health care is a right and not a privilege. In term of the gamble and the Supreme Court case. What the Supreme Court ruled was that the responsibility of a jurisdiction is to not be dlib letly indifferent to the Health Care Needs of an individual. So, for example, if you had a lawyer going back to your example, deborah, waiting a year to get a dental appointment. That dental appointment was made i wasnt deliberately indifferent to that persons need and i go back to Regulatory Frameworks, okay . That if again, how we do managed care within a Community Setting we require a certain number of days after which an appointment has to be made and we require a certain number of credentialing to provide care within the context. We dont do that in Correctional Health at this point and were still on an island and thats the point that well say over and over again this afternoon. All right. I dont want to cut people off, but i do want to give us the benefit of our last two panel t panelists. Jacqueline, deborah, thank you so much and if youll be sticking around anyway maybe well find stray questions at the end of the q and a for the second panel. Thank you so much. Thank you. [ applause ] and our nascar second panelists could come up, if i could. Theyre good. All right. Ry are reconstituted panel wise. Youve heard from Steve Rosenberg and the other panelists on my right, dr. Sharon lewis medical director for the Georgia Department of corrections. Shes a boardcertified pediatrician and a nationally respected expert on Quality Assurance with more than 20 years of experience in health care and managed care and right now shes responsible for delivering adequate and costefficient care to the inmates in the georgia correctional system. Next to her is dr. Asher turney who is the medical director for centurion of tennessee which is a joint venture of centene with which tennessee contracts to provide health Care Services for its correctional system. Dr. Turney is Board Certified in both urgent care and occupational medicine and hes got a special interest in Health Inequalities in the health of vulnerable workers. Welcome to both of you, and i would ask i guess we need to pass the clicker to the lady who is next. Dr. Lewis. Good afternoon. As you all heard, i am a boardcertified pediatrician, so i tell folks that i have 55,000 bad kidses under my care. What id like to do is to give you an overview of the Georgia Department of corrections which i think is a reflection of a lot of other correctional departments throughout the throughout the United States. Fortunately, weve had lots of success in improving the health care that is being delivered to the inmates in our custody and fully respect theestel versus gamble ruling with mandated health care. To start out, georgia has a little bit of a difference here. Were the ninth largest state in overall population, but with the fifth largest prison population. We have roughly 55,000 offenders in prison and about 145,000 probationers. 94 of our population is male and 6 is female, and i think that this is, again, a reflection of other states. The male population, unfortunately has a predominance of africanamericans. 62 of our population is age 25 to 45 chronologically and ill speak a little bit more in just a second about that. 50 is over 35. So you think about your general population in the free world and how we mirror what is in the free world. We operate 120 facilities, 31 of those are prisons. We also operate county and private prisons, transitional day care and Day Reporting Centers and probation Detention Centers and boot camps and again, were responsible for producing constitutional providing constitutionalmandated health care. Does everyone understand what that is . It means there are basically three minimal standards and one is that all inmates have the right to access care. Secondly, they have the right to care that is ordered and thirdly, they have the right to professional opinions of those providers to order that care such that the example that i give is that we cant have a dentist that tries to do an appendectomy, so thats the third piece of it. Our demographics are such that 37 of the inmate population has significant chronic illness. That number in percent is up after about four years. Four years ago it was about 33 , and i think that every state is challenged with this where they have an increase acute to chronic disease and the disease is the most prevalent and our hiv, cardiac, hepatitis c and Mental Illness and cancer. 17 of the Georgia Population receives Mental Health services and theres some difference with that. In the female population, 50 of our female population is receiving Mental Health Services Compared to about 12 in the male population and we think thats attributed to cultural differences and then mostly in the female and it is behavior disorders and it is the mood disorders. We have most of our inmates we say kron logic age, their physiologic age exceeds their kron logic age because it exceeds incarceration. They have drug use, lifestyle factors of smoking, deficiencies and lack of activity. They have minimal to no health care, either medical, dental or Mental Health and have an accelerated listing of chronic diseases. We have an increased population of aged, blind and disabled and our older, our admission age is older. The average now is about 33 years of age and then it therefore translates into our older age of the population which is about 36 years. So were not getting more young people in that i call, but rather, you know, the older folks are starting to come in. In fiscal year 2013, these are some pretty startling statistics for us. Those that are over 35 years of age represent 54 of our population and account for 75 of the claims. Those that are over 50 years of age are 18 of the population and account for 47 of the claims, but most importantly here is those that are over 65 represent 2 of our population, but account for 8 of the claims. So if youre looking at 180 million budget, thats a lot of money. Those that are over 65 years of age and their average claim cost thats around 3500 versus those that are less than 65 years of age representing only 591 and thats a dramatic difference just based on the age. Here, id like to look at the per diem budget. Over the last, at least five years, each year the department of corrections has been given a reduced budget. So we have this budget that is continuing to be reduced. We have the mandated Constitutional Health care that we have to provide. We are continuously having an intake of chronic illness which includes those women that come into our population pregnant and were responsible for the prenatal care and delivery and they would be high risk so all of the services that we are required to pride, were having to get very creative in the strategies that we use in order to provide that necessary mandated health care. The covered population that you see listed below represents the population thats covered in our general population. We have probably about 6,000 inmates who are housed in wha