Training posture and both for military and rest of the economy. Again i think weve not been arguing for a certain size of the military been arguing for the competitiveness of the nation. Both on the military sides and also economically. I think that is a huge question that youre hearing in innovation space but also in skills and then the defense Manufacturing Base which i think were seeing there a, the Technology Side is now, i think lifted. The Manufacturing Base to an extent where it is now much more competitive than it was even though it is not hiring, to the same extent. There is real transition that is about the trend or, for Defense Budget but then what about the rest of the budget if and or, are there other sources for delivering these services that are needed so that we can leverage. Unless there are any final words, well recognize there are a lot more topics where we havent come up with industrial policy for solving the was ton nationals decline among other topics. We have full agenda including bens book but thank you all very much for being here. [applause] [inaudible conversations]. [inaudible conversations]. [inaudible conversations]. [inaudible conversations]. Julian bond, a leading figure in the Civil Rights Movement and former chair of the naacp died over the weekend at age of 75. Mr. Bond had a long career in politics, serving in the Georgia State legislature and was cofounder of the southern poverty law center. In an interview in 2011 he was asked about the state of Race Relations in america since the election of president obama. What has it meant for the Civil Rights Movement which youve been involved in, with, for your entire life, and still are, as chair emeritus of the naacp, to have a black man elected to president of the United States . Well it means the work weve been doing since 1909 has been worthwhile. We were talking together and joked upstairs about the headline in the onion the day after obamas election. Black man gets worst job in the United States. [laughing] but it means that the work weve been doing for all these years has paid off. It doesnt mean that work is over. There is more work to be done. But, no one can believe that barack obama would be president of the United States had it not been for the work the naacp and many other organizations, many groups and individuals, for the work done by these people and these groups over the past several years. So it was like vindication that all of this labor, all of this effort has been worthwhile. Were happy to be able to do it and see results of it. You know he spoke at our convention in 1909 im sorry, in 1999, our centennial convention, is that right . 2009, thank you. My wife is here in the front row and, many, many wonderful purposes. [laughing] one of them is correcting me. nx im glad she did that because i couldnt get it right either. The at any rate, he spoke to our convention in 2009, and, you know, we were so happy to see him. He spoke to us as senator obama. He spoke to us as candidate obama running for the presidency. He spoke to us as nominee for the Democratic Party and have him come to us as president was a great, great thrill for all of us. When he was first running, and even after he was nominated, there were civil rights veterans, members of your and my generation, who seemed to be resentful, particularly because he had not lived what they regarded as the black experience. I think Jesse Jackson was probably the most prominent of those who seemed to be unhappy about him in that respect. Is that important . It is important, i think it is important to note but also important to note that reverend jackson became a strong supporter and is a strong supporter today, campaigned vigorously for him. Im sure will be campaigning again when he announces his formal campaign or when he undertakes his formal campaign for reelection. Many of those people who felt that way, i felt that he would make a wonderful president. I had friends in chicago kept telling me we have this great state senator, he will be president some day. I would say, ah sure. He is u. S. Senator. He is u. S. Senator now and they would say, ah, sure. Ran and won a couple primaries, and said, oh, sure. He won in iowa, if he can win in the whitest of states, then he can run all the way, he can become president of the United States. I became a convert then. I hadnt been a convert before. I didnt not support him because i disliked him in any way. I just didnt think it was possible. I wasnt going to waste my vote. He proved to my could win andnl happy to support him. nx we have an africanamerican family in the white house. Africanamericans in the United States are stillnx disproportionately suffering from poverty, ill health, poor schools, all of other ailments that you have worked so hard to correct in many ways, succeeded in correcting but not in every way. Is it harder now to argue for affirmative action, to argue for issues, argue issues of that kind . Its a little bit harder because theres, this feeling in the population that having elect ad black man, that these problems have been solved and gone away of the remedies that solved these problems are no longer needed anymore. That is false thinking. That is not true. The fact that a black man in the white house doesnt mean the country has become a wonderful place where everything is happy and everything is fair and equal but because many people do believe that, it is harder to argue for these things. Well argue for them nonetheless. You can watch that entire interview at cspan. Org. President obama issued a statement on the death of julian bond saying in part, michelle and i have benefited from his example, his counsel and his friendship and we offer our prayers and sympathies to his wife pamela and his children. Julian bond helped change this country for the better. Tonight on the communicators he was really into computers and the scifi and that pushed him and then he would always heard about Silicon Valley and dreamed of getting to america. So from a very young age that is what he pined to do and at 17, he ran away from home and did it. Bloomberg business Week Technology reporter ashley vance, one much Silicon Valleys most inventive leaders, elon musk. In Silicon Valley he is seen as the next steve jobs kind of figure. I actually, there are bits of him like that for sure. He has attention to details. He pushes his workers really hard. I tend to lean more this edison kind of idea although elon has a lot to prove. What i have taken away he is a guy that gets thousands of engineers and spacex, test last, brightest of the bright and very hardworking individuals and really is able to get products out of them that can be commercialized and really changed industry. If you look to me, to me he is a , combined software and hardware and atoms and bits in a way no one has been able. Tonight one the communicators on cspan2. With the senate in its august break, well feature booktv programing weeknights. In prime time on cspan too, starting 8 00 p. M. Eastern. For the weekends here are a few booktv special programs. Saturday, were live from jackson, mississippi, for the inaugural mississippi book festival, beginning at 11 30 a. M. Eastern, with discussions on harper lee, civil rights and the civil war. On saturday, september this, were live from our nations capitol for the 15th annual National Book festival. Followed on sunday with our live in depth program, with former second lady and senior fellow at American Enterprise institute, lynne cheney. Booktv on cspan2, television for serious readers. The white house announced steps today to deal with heroin across the u. S. It includes 2 1 2 Million Dollars for regional coordinators to oversee response in 15 states hardhit by heroin addiction of the most are in the northeast. There will be coordinators dealing with the health aspect and another coordinator who will work with local Law Enforcement a Congressional Committee has been look into heroin abuse. Last month members heard from officials from the Drug Enforcement agency, white house and other federal agencies. They testified what has led to the problem and ways to stop increase of heroin abuse. This hearing is an hour 15 minutes. The subcommittee will be in order. Without objection the chair will be authorized to declare recesses this morning at anytime we welcome our Witnesses Today. Our nation faces a profound challenge with the growing heroin epidemic. Last year the number of heroinrelated deaths in milwaukee county, wisconsin, which includes part of my district, grew by a shock 72 . While superior northwestern wisconsin suffered six overdoses in six days this past february. Clearly this is a problem that does not discriminate by race, or class and transcends geography. Earlier this year the White House Office of National Drug control policy released the 2013 Drug Overdose mortality data from the centers of Disease Control and prevention. The data shows that while drug deaths related to prescription opioids has remained stable since 2012, the mortality rate associated with heroin increased by 39 , more than triple the levels in 2012. That represents the third year in a row the number of heroin deaths has increased nationwide. This past weekend the Washington Post report ad tragic story of a tragedy in maine and nearly a second. The heroin was laced with an opioid analgesic, 80 to 100 times more powerful than more fine. Heroin cut with fenitel has been a responsible for a rash of overdoses and deaths across the country. Shockingly the fact that a particular batch of heroin has killed someone is often what attracts addicts to it, because they know it will deliver extremely potent high. It is obvious then that the solution to this problem must involve appropriate access to treatment as well as enforcement. That is why earlier this year i introduced hr 953, the comprehensive addiction and recovery act of 2015. This hedge shun would take a number of important steps to combat the heroin epidemic. For example the bill addresses the link between prescription opioids and heroin by requiring the department of health and Human Services to convene a task force to develop best practices for Pain Management and in prescribing Prescription Drugs and share those with the appropriate authorities. The legislation also authorizes grants to provide for alternatives to incarceration for veterans as well as those individuals with a Substance Abuse disorder, Mental Illness or both. Finally it would give priority to awarding grants to those states that provide civil Liability Protection for firstresponders, Health Professionals and family members administrating the noxodone to counter act opioid overdoses. I introduced a bipartisan criminal Justice Reform act, the safe justice act. This legislation promotes drug and Substance Abuse treatment programs over harsh irsentences. We know that 60 of the prisoners have addiction disorders but only 11 receive treatment. No wonder recidivism rates are higher than they are. This is not a argue that we can simply incarcerate ourselves out of. It would authorize medication assisted treatment in treatment of opioid dependence in the bureau of prisons and residential Substance Abuse treatment programs. Training to federal Law Enforcement officials to better identify and respond to individuals with the drug and Substance Abuse issues. I look forward to hearing from the Witnesses Today about additional approaches to curb this epidemic. And at this time i would like to yield to the gentlewoman from california who is the Ranking Member pro tem of this subcommittee today. Miss chu. Thank you, mr. Chair. Todays hearing concerns finding best means to respond to the increasings use of heroin in this country which is tragically proving to be more deadly than in the past. Despite the heroic efforts of our federal Law Enforcement and dea the volume of heroin coming into this country continues to rise. Every year brings new records in amounts of drugs seized at our border by interdiction programs. From 2008 to 2012, the dea noticed 232 increase in heroin seizures along americas southwest border. The rate of state and local Law Enforcement seizures of heroin continue to rise as well. Still, the current level of heroin use indicates that the substance widely available. It is cheaper to acquire and has no geographical boundaries. Over 600,000 americans use heroin to combat or compound the health risk that imposes. The heroin sold today is more potent and deadly than ever before. Deaths due to overdose have risen significantly in the last several years. In the last reported year of 2013, 8257 people died from heroin overdose and additional 16,235 died from opioids. Heroin overdoses in the u. S. Have nearly tripled between the years of 2010 and 2013 according to the cdc. Deaths due to heroin overdose now exceed Traffic Accident deaths in the u. S. It is time that we acknowledge the fact that we are dealing with a Public Health care crisis driven by a Strong Demand for opioid drugs. Where does this great demand come from . Most experts agree that prior to increased use of heroin, millions of americans became addicted to opioid Prescription Drugs. The correlation is so strong that experts believe 80 of current heroin users began as abusers of prescription painkillers. To complete the perfect storm the price of heroin has fallen to new lows, five to 10 per day. In comparison to prescription opioids cost about 80 a day. For those already addicted to an opioid Prescription Drug, heroin becomes an attractive option. In response many states are implementing drug treatment programs for those addicted to both Prescription Drugs and heroin. State reactions include revisiting older forms of treatment such as methadone maintenance and new programs for better oversight of prescription medications. Many Police Departments across the country are employing use of a drug naloxone, an antidote to heroin overdose to reduce deaths. Hundreds of Police Departments in 29 states that stock and administer naloxone. It is credited with saving lives of over 10,000 americans since 1996. Police departments are working with Prosecutors Offices across the country to create programs to divert users to Treatment Facilities rather than courts, detention facilities and prisons. This effort support as more permanent solution to the Health Crisis we face. It reduces crime rates and expenses of incarceration while allowing courts and Police Departments to allocate resources in a matter bestsuited to protecting our citizens. As we consider proposals to address increased use of heroin we would do well to consider the lessons of prior responses to drug abuse. Incarcerationenforced approach has not solved this Public Health crisis. Our focus should to be eliminate impediments to delivering Substance Abuse treatment to those in need, reduce the harms posed by heroin and educate our citizens to prevent substance addictions. I look forward to the discussion of this problem and the west ways best ways that government can help address it. Oh, and i would like to submit for the record a letter from the drug policy alliance. Without objection, the record will be so he will bell liked. I embellished. I recognize the chairman from the full committee, gentleman from virginia, mr. Goodlatte for his opening statement. Thank you, chairman sense send bener im pleased to be here at hearing and to address the growing heroin epidemic use in our nation. Weve skeen alarming increase in availability and use of heroin this not surprisingly has had profound and tragic consequences. Every day it seems brings new stories of Overdose Deaths occurring across the country including in my districts. Since january there have been 11 heroinrelated overdose notice Roanoke Valley resulting in nine deaths. Earlier this year the Washington Post reported legalization and high grade marijuana to American Consumers led mexican drug cartels to increase amounts of heroin and methaphetamine theyre trafficking across the u. S. Mexico border. Since 2009, heroin seizures along the border have nearly tripled as Law Enforcement seized 2181 kilograms of mexican heroin last year alone. These are alarming statistics. However the grim reality is, they should surprise no one. Drug traffic something an extremely profitable business, run by criminals who are interested in one thing, money. Given the increasing availability of marijuana in the United States, and related on going epidemic of heroin use, drug traffickers have decided to cash in on the misery of american citizens. Additionally, the Drug Enforcement administration estimates that the United States has 600,000 heroin users which is three times the number in 2012. Tragically that number is expected to rise. And that is because there are an estimated 10 million americans who are currently addicted to prescription opioids including such drugs as vicodin, oxycontin and perk set. Percocet. Once someone is addicted to prescription opioid. It is far easier to pay 10 for a dose of heroin than 80 for an oxycodone tablet. It is no exaggeration to say heroin use has reached epidemic levels across the nation including my home state of virginia it is not an urban or rural problem but american Public Health and safety problem. Despite increase in heroin and meth production, despite the ongoing heroin epidemic, despite dramatic surge in deaths and despite clear evidence that illicit controlled substances and their purveyors pose a lethal threat to the American People the Obama Administration continue to shirk it is duty to protect the nation from dangerous narcotics. I believe any solution to the heroin epidemic must have three parts. One, discouraging the use of this dangerous, highly addictive drug. Two, providing appropriate treatment to addicts and three, insuring Law Enforcement zealously pursues the criminals who bring this poison into our communities. I look forward to the witnesses testimony today. Today we have, without objection, all members opening estimates will appear in the record at this point. We have a very distinguished panel today and i will begin by swearing in our witnesses before introducing them. If you would, please all rise. Do you solemnly swear that the testimony youre about to give to this subcommittee is the truth, the whole truth and nothing but the truth, so help you god . Let the record reflect that all of the witnesses responded in the affirmative. The gentleman from virginia, mr. Forbes, has a distinguished witness and i will allow him to introduce the commonwealths attorney parr at this point and i introduce the next three witness. Thank you, chairman sensenbrenner, for holding this important hearing today and inviting our distinguished guests to share their persons. As you mentioned one of our Witnesses Today is nancy parr who served as Commonwealth Attorney for city of chesapeake since first being elected in 2005. During her 10 years of service she has implemented new programs an promoted Community Outreach in addition to carrying out the traditional role of a Prosecutors Office in chesapeake. Her programs include seven girls empowerment conferences, four boys leadership conferences, seven traveling the road to success multiweek programs and five playing on the right Team Basketball tournaments. Prior to her current role, miss parr was a prosecutor in suffolk for 10 years. Before that worked in chesapeake since 1994. For six of those years she also served aspects assistant United States attorney in the Eastern District of virginia. In addition to her Public Service she is member of many boards and organizations an volunteers her time to charitable organizations including the Virginia Association of commonwealths attorneys where she was president from 2014 to 2015. Commonwealth attorneys serve as counsel where she was chairman 2014 to 2015. State crime commission, Governors Task force on Prescription Drug and heroin abuse, secure Commonwealth Panel subcommittee, Justice Reinvestment Initiative work group, board of correctional education, Virginia State bar council, board of governors for the criminal law section of the Virginia State bar, virginias adult fatality review team, state child fatality review team, Domestic Violence advisory committee, boys and girls clubs of southeast virginia, Chesapeake Division and womens club of south norfolk. Miss parr is graduate from university of virginia with high distinction and tc Williams School of law at university of richmond. Thank you for accepting our invitation today and i look forward to hearing your testimony as you share with the commit me more about the efforts youre championing in my district and hometown. With that i yield to chairman sensenbrenner to introduce the other witness. Thank you very much, mr. Forbes. First mr. Michael botticelli, is the director of National Drug control policy where he served since november of 2012. Previously mr. Botticelli served as director of the bureau of Substance Abuse services at the Massachusetts Department of Public Health. Holed as bachelor of arts data college and masters of from st. Lawrence university. Mr. Jack riley is acting deputy administrator of the Drug Enforcement administration. Highest ranking Career Special agent at the dea. Prior to appointment of chief of operations mr. Reilly served in many other leadership positions during his distinguished career at dea he received a bachelor of science degree in criminal justice from practicedly university and masters degree in Public Policy administration from the university of illinois. Police angela pa check coy was first woman elected to the District Attorneys Office. Her legal career consisted primarily criminal prosecution which she tried a number of highprofile cases. Prior to becoming an attorney miss pacheco worked as a social worker for 13 years in northern new mexico. She received a bachelor of arts in social work from the college of santa fe and her juries doctorate from the Hamlin University school of law. I would ask each of you to summarize your testimony. Without objection the witnesses written statements will be entered into the record in their entirety. You have something with a red, yellow and green light in front of each of you. I assume that you know what all of that means. So, mr. Botticelli, youre first. Chairman sensenbrenner, chairman good late, representative chu, members of the subcommittee thank you for opportunity to be here to discuss the administrations response to epidemic of opioid abuse and particularly rise in heroin use and Overdose Deaths. Approximately 18 billion opioid bills were dispensed in 2012. This is enough to get every american 18 years and older 75 pain pills. Even the data indicate over 95 a prescription opioid users cannot initiate heroin use, four out of five new users have used Prescription Drugs nonmedically. Given this relationship we cannot develop a Public Health response to heroin use without making a part of a response to prescription to opioid use. While heroin is traditional regard it as an issue facing large urban areas we are seeing a shift in the demographic of heroin just. Increasingly heroin gives come Overdose Deaths and the consequences are being seen in suburban and small town america. The recent cdc study shows aer lingus rates britains highest a young males a it is doubling among women and has more than doubled among nonhispanic white. We also know from the same study past year ill call, marijuana, cocaine and of your families or misuse our dependence were used to get each risk factors. Ondcp is used its role as coding of the federal drug control agencies to bolster support for treatment and Overdose Prevention efforts. And coordinate a governmentwide response. And 2011 the administrations plan to address the sharp rise in prescription opioid drug misuse was released. This plan contains action items categorized into four categories. Education, increased drug monitoring programs, proper medication disposal, and Law Enforcement efforts. Recently the administration convinced congressional mandated in the agency and when task force cochaired by ondcp and the department of justice to a close examine the ministrations efforts and to advise recommendations in what more we can do. Weve seen overdose from prescription opioid leveling off by the force would this has been coupled with the 39 increase in heroin deaths from 20122013. To address the overdose death issue weve been working to increase access to lock some diverse respond and it was close to the opioid drug use disorders. Handinhand with these efforts our efforts to promote Good Samaritan laws so witnesses dont overdose will take steps to stabilize. Law enforcement nationwide has risen to this challenge of increase in oak ridge is an overdose death. They are working handinhand with members of the Public Health community but its important for the medical establishment to work with us to meet the challenges of increasing access to treatment for individuals with open gives the source. Riemer care physicians have the opportunity for Early Intervention as to Emergency Department physicians to treat Substance Abuse t disorientig thing before they become chronic. As final individuals with over use disorders receive evidencebased care and treatment. Medicationassisted treatment with sba approved medications when combined with chemotherapys and recovery has shown to be the most effective treatment or open abuse disorders. Just this week in secretary burwell announced an additional 33 million in funding, an additional 100 million to fund improve access to care and services that Community Health centers nationwide. Hhs is raisin raising guidance o assist up and put innovative approaches to Substance Abuse disorder treatment. The administration has proposed 99 million into fy 16 budget because over fy 15, for treatment and prevention efforts. In addition given the connection to an injection over drugs and Infectious Disease transmissions Public Health strategies are nested to prevent the further spread of Infectious Disease. The recent hiv and hepatitis c outbreak in indiana is a stark reminder about opioid abuse can spread to other diseases. How comprehensive Public Health measures such as surrender Services Programs need to be part of the response a number of communities with limited treatment capacity they experienced additional Public Health crises. In conclusion, will continue to work with congress and our federal partners of the Public Health and Public Safety issues resulting from epidemic of nonmedical prescription opa just and heroin just. Thank you for your time. Thank you, mr. Botticelli. Mr. Reilly. Chairman sensenbrenner, chairman goodlatte, distinguished members of the subcommittee thanks for the opportunity to discuss hair went to a just and availability the epas response. Deas Single Mission is important to control of its enforcement act. Harewood has always been major focus of our efforts over the years. Sadly today 120 americans will die as a result of Drug Overdose. Heroin and prescription painkillers cause over half of those fatalities. According to dea is opioid addiction epidemic is the number one problem facing the country. Ive been with dea almost 30 just sa to say ive never seen t this bad the heroin destroys individuals, families and communities, the vast majority of it abused its manufacture outside of our country and smuggled across the southwest border we have seen an increase in cultivation and production in mexico but as a result mexican harewood is more prevalent on our streets today accounted for approximately half of the domestic supply. The role of the mexican organized crime this unprecedented which is what deas relationship with the mexican counterparts and are present along the border is so fun. Deas addresses evolving so by targeting the highest level traffickers and organizations they run. I processed that the bulk of my career jason metaagency to be the most dangerous heroin dealer in the world, chop up and. He and his cartel dominates the u. S. Heroin market. Be a focuses its resources on disrupting and dismantling these organizations both home and abroad. That means targeting the intersections between mexican organized crime and violent urban gangsta stripping hair went on their behalf. The relationship between these two cruel entities can only be described as dangerous and toxic heroin can be found in virtually every corner of our country in places ive never seen it before. Large and small urban and rural. Today it went this far more different than five years ago. Cheaper, higher in purity and bespoke and stored much like powder cocaine. Unfortunate there is no typical heroin addict the problem transcends all demographic and social and economic life. Knowing this drug is a source of so much violence in our communities is what keeps me up at night. I know the more we do to reduce drug crime the more will do to reduce all Violent Crimes. Special agent in charge of chicago to the vision, we developed a model Cooperation Collaboration that i believe is making a difference there and across the country. Chicago airman strikeforce begin with you should believe among federal, state and local Law Enforcement, political leaders and Community Leaders and prosecutors that together we could effectively target violent heroin organizations trafficking in heroin. As a result of our efforts primarily connected violate the we also dismantled criminal or positions responsible for the district of hundred, thousands of kilos of heroin and other drugs. Consequently we made our communities safe. This new strategy allows us to work at the street level to prevent Violent Crime while at the same time to pursue the investigation into the highest level of Cartel Leadership were ever that takes us. We are looking to make this the dea model across the country. Just as we ca cannot separate fs from drugs we cannot separate control Prescription Drug abuse in heroin. As a result eea is established effective tactical diversion squad across the country. 66 in total. As part of the commitment towards the critical nexus between the diversion of Prescription Drugs and heroin. We are taking steps to remove unwanted unneeded an expired Prescription Drugs or medicine captors. On september 26, 2015 dea will host 10 National Takeback initiative. I know firsthand these threats are an urgent challenge any change to the communities in the lives of our citizens. But Law Enforcement is not the sole answer. Prevention, treatment, education awareness are critical to our success. Everybody placeable in these problems from parents, Community Leaders, educators, faithbased organizations, cultures and athletes and the medical community. This is a marathon not a sprint but together we will produce the results you seek in the American People demand. Thank you. Thank you, mr. Reilly. Mr. Chairman, appreciate the opportunity to be heard today and speak to you. For the past 1218 months ive learned a great deal about Drug Overdose deaths, prescription and illegal drugs. Part of that is because i served on the state child review team and we are reviewing for things are used and that includes narcotics. And also within the adult overdose and just in my city. For the past 30 years as a prosecutor ive learned a lot about history being drugs and ive learned about simply possessing drugs. There is a difference, a big difference. For the past 30 years as a prosecutor i learned a lot about property crimes, Public Safety and what victims of crime and law abiding citizens expect and deserve from the local Law Enforcement and from the state Law Enforcement. I appreciate the hold the drugs have on some people. We may all have family or friends or friends of children who are addicted to be their Prescription Drugs or heroin or cocaine. I appreciate the pain that they experience for what they go through. And i appreciate the verge of people who are addicted to drugs or do anything can break the cycle of addiction by themselves and alone. But i also know that many of them die alone. And i also know that we all want to save lives. Users, whether they are incarcerated or not should have access to good affordable treatment. Dealers should be incarcerated. Storeowners should not have their merchandise stolen by ethics who are in their stealing to support their habit. Law abiding citizens should be able to live peacefully in their homes and in their neighborhoods without dealers servicing the clients on the Street Corners, in the parking lots, or in the house next door. And they should also not be subject to being in the middle of a crossfire when the wars break out amongst the gains and the drug dealers over whos going to run what Street Corner or what street. We have innocent people being shot and killed throughout this country because of drug dealers engaging in gunfire. But generations before us to to find a way to stop drug use or abuse. I dont think anybody realistically thinks that just this generation is going to do so either, but we dont Work Together to diminish of the devastation of the impact of the drug. Now, all of the disciplines involved in this have to be at the table because i am a prosecutor, not a therapist. I dont know what therapies work. I can listen and i can learn so it all have to be at the table. The conference of addiction and recovery act i support very strongly, and i have a mission for the National Association to state that the association supports but also. Because its a three important things t. The connection between Prescription Drugs and heroin use, alternative evidencebased programs for incarcerated veterans, Substance Abuse and Mental Health. They all go hand in hand together. And grant for money for naloxone, for local Law Enforcement. To our five components and each one serves a very valid are this. Prevention, intervention, treatment, diversion and incarceration. Thank you spent thank you very much. Ms. Pacheco. Good morning, chairman sensenbrenner and members of the committee. Thank you for the opportunity to appear today. My name is Angela Pacheco and the elected da for new mexico. I am here to talk to you about hope. As a prosecutor every day i make dozens of decisions that impact someones life. I consider and tell you all the horrors associated with drug use. But as an elected official who is constantly being bombarded with the ills of society on a daily basis, wouldnt you rather hear about giving someone help . If you like some have experienced the ravages of heroin addiction for years. As a prosecutor i have personally prosecuted three generations of families addicted to heroin and associated crimes. Every day in the courtroom we see the same individuals addicted to opiates day in and day out, were released from custody and told to obey all laws and stake claim with little to no treatment. And, of course, in two weeks when the report to a probation officer they would be given a urine specimen cup, told to provide a urine sample, the sample test positive for opiates. And the person would be arrested, placed in custody, goes back to the court and has released from custody, told to obey all laws, state going and the cycle continues. We all know that the person is addicted to heroin. Of course, they will test positive. Just because someone tells them were orders them to stop using, do you really think thats going to last very long . Anyone has ever raised children knows firsthand that you cant make someone do something unless they want to. The definition of insanity is to keep repeating the same mistakes over and over and expecting different results. That is madness. So in 2014, santa fe became the second seed in the nation after the city of seattle to implement a Law Enforcement assisted Diversion Program refer to as lead for lowlevel drug offenders. Hourly program is Community Policing at its best. A Police Officer on the streets knows his or her community. Who better than a Police Officer to divert someone into a program . Let me tell you how it works. A Police Officer is called a local Grocery Store on a shoplifting call. Where he encounters mary, and known heroin addict. That he is arrested several times before. Instead of booking and arresting her, he offers her the lead program. The agreement he makes with mary is that she must complete the lead application process within 72 hours. If she does, the officer will not file criminal charges on a shoplifting at the Grocery Store. If she agrees, the officer then contacts a lead case manager and arranges for the to to me. The case manager asks mary, what can i do to help you . What do you need . Then the two of them develop an action plan. They start with what our basic needs. For example, she may need housing, childcare, assistance in the layout a job application, or a ged registration. Whatever it takes to get her life back. Remember, mary has been through the system and has lost everything due to her addiction to heroin, friends, family and children. Lead has a Case Management committee that meets every two weeks to discuss marys progress. The committee consists of Police Officers, prosecutors, public defenders, case managers and therapist the value is given an opportunity to provide input on marys progress. Everyone is in agreement that mary will slip and there will be missteps, mary will have a safety net ready to support her. Hourly program isnt for everyone but its a start for a number of reasons. Its about understanding that in opiate addiction is to a Public Health issue and not a criminal matter that its about recognizing that a person with an opiate addiction is a person, not just another statistic, not another criminal defendant for me to prosecute but someone whose life does matter. The twin purposes are to save money and time. Also but more importantly lead is about saving lives. Lead is about empowering the person and giving them hope. Thank you very much. We will begin questions under the five minute rule, and i will yield myself five minutes to ask the first series of questions. This pacheco ms. Pacheco, i agree with you merely throwing some in jail and having them come out probably go back to the bad boys that i got into jail in the first place is something that ought to be addressed. Can you give me an estimate if the recidivism rate of those who have gone through the lead program and graduated and ended up finding out, everybody finds out that it didnt work . Certainly, mr. Chairman. The program has been in existence for one year and as such we dont have the kind of statistical data that lets a seattle does. Seattle has shown that in the program, the santa fe is modeled after, the recidivism is let me just, i want to make sure i have the correct number for you. Its that let me see, i had marked here for you. Im sorry, sir. It would be 80 less. Its 80 less than recidivism rate before the program started in seattle . Correct. Let me say that they think this is probably the most important thing that we ought to look at. Because as demand goes down, the profits that are made as the demand goes down, the profits that are made by the dealers go down as well. We can talk about saving lives and giving people hope. In my Home Community in southeastern wisconsin weve had a rash of deaths as a result of heroin overdose. Attorney general of wisconsin last week convened a task force to try to deal with this both from Law Enforcement as well as a treatment and rehabilitation standpoint. And the bill i introduced with other members of the committee was made at the suggestion of governor walker. What advice would you give to the eternal general of Wisconsin Attorney general of wisconsin would have to do with the task force he is conveying so they can be effective . Why dont you start, mr. Botticelli . One of the areas i think you are today, and within which with many states and attorneys general in terms of helping the state responses to that, i think the overall goal is that it has to be a comprehensive response, that people know quite honestly that its a multidimensional problem that needs a multipronged approach. For prevention, treatment, Recovery Support services as well as several for local Law Enforcement in terms of not about incarcerated people with addiction but going after the supply of drugs on our street that is doing this epidemic. It needs to be a multipronged approach. As you mentioned i think many local Law Enforcement people are understanding the fact that they cant arrest the way out of this and they have a role in terms of reducing overdoses. So we have really been i think amazed in terms of local Law Enforcement kind of rise to the call in terms of vivendi overdoses. Because of a multidimensional issue that requires a comprehensive response. Everybody asked me, talked about has a role. Whether thats Law Enforcement, public help committee, faith leaders, its about bringing people together, looking at the evidence about whats effective at implementing those responses. Ms. Parr, give anything to add . Mr. Chairman, i am serving on the Governors Task force, there will task force, and i can say that one of the good things and i think this task force is working and information plan has been published is that there are so many different aspects. Where pharmacists, medical doctors, Mental Health treatment providers, Law Enforcement, state police, local police, sheriffs get where the federal government has a representative there. We are all represented there and its been broken down for treatment, workgroup, Law Enforcement work group, education and also more specific on disposal, safe disposal of the Prescription Drug. So that, the broadspectrum and breaking down the specific workgroups i think has produced a very different plan. My time is up to the gentleman from california. Yes. Ms. Pacheco, im so impressed by the l. E. A. D. Program. Could you describe how it is affected police and kennedy relations in santa fe, and what role the committee of all the plays as well as what cost savings have been realized by implementing this program . Thank you, mr. Chairman. Ms. Chu, initially santa fe had a series of meetings by all Community Members for about nine months. We did a Needs Assessment the human was involved private, business, Law Enforcement, Mental Health workers, and were able to put together the l. E. A. D. Program. The l. E. A. D. Program consists of consortium of individual. Santa fe county, city of santa fe, Santa Fe Police department and the District Attorneys Office and the public defenders office. And all of us get together and we have combined resources, manpower. We have public funding, private funding, and we get together and, well, guess what it really would like to say is its really wonderful to see how the Police Officers have responded to this. The Police Officers on the streets are the one who covered the came to us and said we need to do something. We are sick and tired of arresting the same people. We have nothing we can give them. For us its been very gratifying to see the response by the police department. The other thing thats been very gratifying for us in reference to the program has been that weve seen many young women with children and would not anticipated that. So we are also able to provide services to children and we really at first had not taken that into consideration. What we are able to do that is provide services to an entire family. We found that the very gratifying. Thank you. Mr. Reilly, there have been numerous cases across the country were individuals who suffer chronic pain to face the challenge of getting to properly prescribed pain medication. And i understand that drugstores have been tightened the rules after the dea has imposed record fines on pharmacies based on allegations they were not scrutinizing questionable prescriptions. And i believe a careful balance has to be struck between attacking Prescription Drug abuse while not preventing legitimate patients from accessing pain medication. Thats why im cosponsored h. R. 471 which is the ensuring Patient Access and effective Drug Enforcement act which passed the house in april. So mr. Reilly, what steps is the dea doing to ensure that patients are getting legitimate prescriptions for drug abuse how to respond to comments that deas actions to stop Prescription Drug abuse are causing an increase in the heroin abuse problem . Thank you, maam. I, too, share the concern on this. We are so concerned about Patient Access at every step. What we want to ensure that legitimate Health Care Provider has access to adequate medication for the patients. One of the biggest ways we are doing that now is our relationship with industry. And are approximate 1. 5 million registrants, of those 900,000 physicians. And by communicating back and forth with them and making sure they understand what we are seeing across the country and trends of addiction and abuse is really brought them in in what we strive to do to make them our allies. So our education of how the visa problem issue of import. And clearly we want to listen from the registrants so its a twoway street. If you look at, for instance, what occurred in florida with a pill mill situation several years ago, literally united storefront, small strip mall with several hundred people lined up around the block at 6 a. M. Waiting for it to open to obtain obviously illegal prescriptions. In those situations we move very quickly to cut that off. Of the 1. 5 million registrants, obviously the vast majority are law abiding by the ones that choose to break the law we take very seriously. But what we really strive for is Patient Access, safe and excessive medications. Thank you. I yield back. Accountable in some cases by. The gentleman from virginia, mr. Goodlatte. Thank you, mr. Chairman. Between urban street gangs and mexican cartels that its frightening to me. Its what keeps me up at night. What we do better than weve ever done is connect the dots. I can tell you chopper bluesman for one thompson plans on the five that cops dont talk to cops. I assure you we do that better now. Our ability to attack organizations and their tentacles as they spread across the country has never been better. Are these organizations by their nature violence . There is note doubt in my mind having done this job for 30 years. A recent violence connected to trafficking. The are these the people youre trafficking . Many organizations that are violent. They make how many drug possession offenders come in many of those that possess only enough for personal use does the dea referred for federal prosecution . In my experience virtually none. Our goal is to attack the highest levels possible so we can really hurt the organization from start to finish. With limited resources, that is the most effective way for us to make a difference across the country. The mcnamee turned to ms. Pacheco and asked the question. Is the regularly association with Drug Trafficking . Yes. I definitely agree with that station statement. Chesapeake is a very safe community. We have our shooting mainly between a gang who are fighting over turf to where they sell their drugs. What violence you see us as needed with trained to use and distribution . The heroin views, the violence is whether property crimes for heroin users because they used to support their habit. We seen an increase in prostitution because that is the way some people make their money to support their habit. As far as distributing heroin, that would be the gun battles on our city streets and in our neighborhood that expose innocent people to gunfire appeared he might does it extend to Gang Violence over turf . Sales territories if you will. We have gangs in chesapeake in all areas of chesapeake. We have over 300 where miles and theres a lot of turf to fight over them when they see an opening they will go there. Is there a nexus between heroin trafficking and other criminal acts by Drug Organizations or games . Yes, sir. Whenever you have Drug Trafficking, you also see an increase in the prostitution coming into the area and also robberies. We have gang members robbing other gang members in the drug dealers robbing and shooting other gang members. Thank you. Ms. Pacheco, is violence regularly associated with Drug Trafficking and distribution . Yes, sir. It is. What violence the new mexico . Theres been many shootings. Weve had a few executions as a result over trafficking. To have the same problem with the nexus turned to a Drug Organization that are the local sales organizations for this and a little cartel and other drug distributions . We are aware of the fact that because we are at borders day, we definitely see heroin coming in from mexico fairly frequently , especially in northern new mexico. I wouldnt say specifically which it is associated with, but a lot of drugs coming from the border. Thank you very much. Thank you, mr. Chairman. The other gentleman from virginia, mr. Wards. Thank you, mr. Chairman. Ms. Pacheco, we are looking at programs to stop recidivism. Have you done any programs to look at the faith these programs that have worked incredibly successful in trying to stop recidivism. Have you done an analysis of that . Specifically, how they looked at their success rate and impediments we are now putting in front of them does not them from doing the work they are doing. Did you make in the investigation . This is a fairly new concept and there isnt a model to compare it to you oftentimes we create new wheels and reinvent the wheel or weve had some incredibly successful programs around the country that we poked one impediment after the other in a complementary role. Mr. Reilly, let me ask you this question following up on the chairman statement. Weve had testimony that today for look across the country, to gang membership of this country would equal the fourthlargest army in the world. Weve also had testimony, both administrations, not a push on just one. The most violent games serving as networks that 85 are coming in here illegally. They are bypassing prevention programs or anything we are doing. It shocked us the other day to find out the secretary of Homeland Security did know we were asking people if they were members of violent gangs before we release them. Do you have any conductivity as to how important those how important those things are in this Distribution Process . They become crucial to the mexican cartels. There are over 150,000 documented street gang members. Largely they make their love supplied by the cartels. Is now their drug of choice in the way they regulate themselves is by the barrel of a gun. This is an enormity in terms of obesity across the country and is extremely toxic and thats why it is important for Law Enforcement to be involved to attack the organization. Not just with occurring on the street. We work with state and local counterparts to intervene violent acts, but to make sure the integrity of those cases are worked to the highest level so we can have an impact on the organization itself in the community. This committee has work to do that under then chairman sensenbrenner taking legislation out here. Unfortunately got bogged down in the senate. Ms. Parr in mr. Riley, on july 14, 5 individuals from portsmouth to chesapeake were arrested on federal conspiracy charges of manufacturing, distributing with intent to distribute as part of an investigation led by the yes the eyes were full field office in Chesapeake Police department. According to documents come in the above 75 kilograms of heroin sold between 2013 and 2015. To put that in perspective, thats equivalent to 2 million doses which is enough to give everyone in Hampton Roads high off of heroin. With that said, can you give us details about those arrested were particularly the level of coordination between local, state and federal government and were there any barriers you would suggest are problematic that we could work on eliminating for you . Mr. Chair, the recent arrest is a crime in great example of cooperation that we have in south Hampton Roads in particular between chesapeake, port and acting u. S. Attorneys office and the dea and fbi. We have worked together quite well in many cases and in this case i did not see any obstacles as everybody was fully aware of what was going on as far as the investigation was going on it was very well organized to the execution of a search warrant. You did state the amount of and the money they were making off with this. And one of those homes there was a search warrant executed in south but here there were many children in the home and the information is 50,000 was counted every other day in that house with those children there because of the heroin sales and heroin was cut and prepared on the dinner table. I think when we look at that and the children exposed, we had to do something. Thank you. My time has expired. Thank you. The gentleman from South Carolina, mr. Gowdy. Thank you, mr. Chairman. Thank you for your service and directs the work is a dea agent in the excellent work of South Carolina who are credit to your agent v. Im not good with math, which means im in the right line of work. I need you to help me a little bit. I think it takes 20 grams of to trigger the fiveyear mandatory minimum. I believe thats true. In 28 grams the to be roughly equivalent to 112 dosage unit assuming. 25 dosage unit. 25 grams per dosage unit. To get five years minimum mandatory need 112 of cocainebased or crack cocaine. And it takes 500 grams of powder to reach the same fiveyear mandatory minimum which should be about 500 dosage units because of disagreement dosage unit when you deal with powder. Yes, sir. No hair when it takes 100 grams of heroin to reach the same threshold but that is 3000 doses im trained dosage units. Why can you go to prison for five years for 28 dosage units of crack cocaine, the 3000 dosage units of heroin is what it takes to trigger the fiveyear mandatory minimum. That just seems absurd to me. Well, clearly on the Law Enforcement side we are cops. We are doing the best we can with the laws currently out there. Ivar. Which is why when there is a discussion about reforming mandatory minimums it is important to hear from Law Enforcement officers. One thing we could do this just equalize what it takes to trigger a mandatory minimum. If youre having a problem with heroin and it requires 3000 dosage units to reach the fiveyear threshold, but it only takes 100 dosage units of crack cocaine, it is pretty easy even for me to say one thing that can be done with respect to heroin. Everybody in congress doesnt like mandatory minimums. Most folks among force meant like them, but most in congress dont like them. How many folks are serving federal prison is for simple possession of a drug . Ive been doing this for 30 years and nobody is a result of my investigations. I couldnt find any either. I couldnt find anybody sitting in a federal prison for simple control. Lowlevel nonviolent offenders, how many of those target for investigation when youre a dea agent . None, sir. Ray. Da wouldnt target lowlevel nonviolent drug offenders that they would go to the state prosecutor, right . We would go after the largest traffickers of the largest organizations. So this mythology that they are full of nonviolent offenders and the statistics that are 30 years a month worsening dont bear that out, today . Not based off the investigations i was involved with. I have a colleague who was a prosecutor and a former life, julie canning from its come a very conscientious colleague from the very first day he stepped foot in congress shared with us his concern about the heroin epidemic and he wanted it is asking to pass the interconnect committee, relationship between Prescription Drugs and heroin. Who can speak to that on behalf of my colleagues, mr. Kennedy, who raises a good question. I think it is a real can learn as we talked about the fourth, fifth in newer users to heroin started using prescription pain medication and some of the economics of what it cost to buy prescription pain medication versus how the peer heroin is. We see that transition and this is where intervention and treatment and did munitions of vast overprescribing happening right now is particularly important in terms of our effort. Ive got 25 seconds. Drug court, tremendous believer in drug court, saul change. Heroin is the hardest drug for folks to quit. What do we need to do to make you wear more folks are getting off of it . Coincidentally i just spoke this morning at the drug court professionals. 5000 people across the country who are saving lives by giving people a second chance, by giving them good care and treatment with accountability. Part of what we know to be effective if medications when combined with other therapies become critically important. The evidence of people with opiate addiction or Prescription Drug addiction fail a significant portion of the time. Weve been working with our treatment programs, with our drug courts and using our federal resources to support increased access to these medications as part of a comprehensive strategy in terms of what we know to be the most effective treatment for people with opioid use disorders. Thank you, mr. Chairman. Petulance time has expired. The gentleman from michigan, mr. Bishop. Thank you, mr. Chairman. Thank you for the panel. Appreciate your testimony on this important issue. As a former local prosecutor myself i had opportunity to prosecute many drugrelated offenses but i can tell you in my experience i never saw this level of heroin in the marketplace. It is troubling. I have School Age Children and i hear too many stories. It is very disconcerting for a parent and someone like me who is an elected government looking for a solution and i appreciate your willingness to be part of the solution making process. I recently met with a group of local Law Enforcement officers, may local county sheriffs and several others to talk about the issue, sheriff brassard and our sheriff Ben Livingston county. The statistics they shared our alarming and may have peaked my interest and i want to do what i can to be part of the solution. In livingston county, they had 34 heroin overdoses that resulted in death last year alone. Oakland county is to have between 40 and 45 harewood related overdoses per year. Last year it over the past two years that number has increased to an average of 200 in England County theater district counted that i represent which includes the capital of our state, lansing, they lansing, their 20th harewood related deaths last year. That number has increased every year exponentially. So why would agree this issue has caused and deserves our immediate attention. I want to thank the chair of this committee, chairman goodlatte and chairman of the subcommittee for raising these issues and making sure we identified these as primary concerns that we do whatever we can to address them. Director, id like to start with u. S. A. Code. It is clear from what im hearing in a district that this issue cuts across all kinds of democratic demographic lines. What are we doing to ensure the response to this epidemic is comprehensive and are we engaging with local leaders, local Law Enforcement . When i was a prosecutor we had collaborative efforts between local Law Enforcement to make eda and i appreciate your comments about drugs or such alternatives as being that is available. Can you share with us more about what youre doing . Acknowledges the fact why we have a federal response is where the rubber meets the road and an obligation of our office to make sure it aint the locals have resources they need to do the work and identify issues and work collaboratively at the state and local level. We have a number of initiatives in addition to federal treatment funding. We also support high in the Drug Trafficking areas which are counties designated as Drug Trafficking areas to work with state and local Law Enforcement to share intelligence, collector cases, many focused on heroin issues. Many programs also continue to support prevention and Education Programs as well so they try to work across the spectrum. Our office also supports drugfree Community Programs and these are programs and grants to support communitybased, locally driven prevention programs at the local level because every Community Looks different but every Community Needs to have key players on board as part of the solution. We relate knowledge and continue to support state and local efforts because we know we can do as much as we cannot the federal level but it requires state and local partnership to make it real. Mr. Riley im wondering if you can share with the legalization of marijuana at the local level, can you tell us how that is influencing the market and whether or not that has led to the increase in heroin in our country and that shifted the focus away from marijuana onto methamphetamine, heroin and other types of drugs. And it goes to the market genius of the cartels. I do believe they have seen the spread of Prescription Drug abuse and they know that at some point that availability does seize, does begin the long road to heroin. We assume that across the country. I believe as much as if that was 10 years ago when we are battling methamphetamine with the help of congress we were able to legislate the primary precursors outcome of pseudoephedrine and ephedrine inside drastic reduction in the amount of domestic laboratories. However, cartels recognize there still was a tremendous addiction issue. So what did they do . They were able to produce methamphetamine and 5100pound croaks and provide that to the areas in which previously had been supported domestically. As i look at this problem, sir, it truly is battling the new face of organized crime and im so glad the committee recognizes what has been troubling me for a while if the connection between domestic street games and cartels. It truly is the new face of organized crime as i see it in this country among force needs to be fluid enough to adapt to attack the relationship because by doing that we can solve violence on the street but at the same time attack the organizations whose ensemble for all the drugs. The gentlemans time has expired. The gentleman from idaho, mr. Labrador. Thank you, mr. Chairman. I would like to thank the witnesses for being here and for your important testimony and the rise of heroin is across the United States. One particular area of concern i would like to address as the expanded population of harewood users. Mr. Riley come in your written testimony mentioned 213,169,000 people over the age of 12 use heroin for the first time in the past year with the average age of firsttime users around 25 years old. You also cited data indicating that those initiates as they are called him 86 were prior Prescription Drug users. I understand her agency is developing a task force to confront the use of trafficking of heroin in america, but what is being done to address the rising prescription of drugs . What we are doing today is important. Awareness is really. Prior to live in chicago i attended a meeting about two years before i departed and there was about 100 concerned people in the room. I attended the same meeting three years later. There were over 2000 people concerned with the whole heroin issue. Unfortunately, many of them were parents. What struck me most is many of those were kids and High School Age kids. For about the Prescription Drug abuse which led to heroin. Many didnt find out they were on the way to the emergency room. It is crucial not only do around the clock. We are doing great work. The awareness of everyone around the community is going to strain the nice as we go after these organizations. When we look at educators, Community Leaders, faithbased practitioners, everybody plays the role and while we do our job going after the bad guys, we cant let alone. We need to help everybody, especially parents. I understand many users are initially receiving Prescription Drugs through legitimate means leading to an increase among traditionally untouched populations. But as the agency proposed are addressing the fundamental problem of addiction. Clearly we are working with different agencies to get the word out. One of the problems we face i think ms awareness issue is todays heroin is being smoked and snorted initially. Initially gone is the fear of aids or hepatitis because of the needle. We see a lot younger people try heroin as a recreational drug. Statistics show they eventually will go to needle years but it does have a lot to do with why we see younger and younger addicts. Mr. Botticelli. Just about to the comment youre focusing on the Prescription Drug album is a top priority. First and foremost we need to reign in over prescribing pain medication and our office has proposed mandatory continuing medical education for every prescriber. Again we want a balanced approach picture people are getting appropriate for pain. We want to make sure every prescriber has at least some minimum education about safe prescribing this is good we know 70 of people who start misusing them are getting them free from friends and family and that is why federal local take as programs get the drugs out of peoples homes become equally important. Weve been providing Prescription Drug monitoring that allows physicians to check databases to see if someone might be going from her doctor to be able to intervene at that point as well as one for his response. The dea in terms of bad doctors and bad practices in the south. We know that this means an holistic response. Thank you very much. Ms. Pacheco, you also mentioned the need to address lowlevel mob violent offenders who wind up in jail with minimum mandatory sentence with no alternative for addressing problems. I agree the minimums strike and address the drug kinds that have resulted in wasting valuable resources. In your view, what is the best alternative for addressing addiction given your experience is in place for a drug addiction is pervasive within the culture . You know, i have been doing this for many, many years, sir. You know, it always comes down to resources and money for drug treatment. But we see over and over the same people in and out without appropriate resources. Mexico as you know is one of the poorer states. We dont have that type of tax base to provide services. A program is a prearrest, prebooking shows that can save us money and the money can then go into treatment and the Wraparound Services that many individuals made because that is kind of where it is not when someone who is in the cycle of addiction need as much support as possible and we are transferring resources from the backend to the frontend to help them and keep them out of the system, sir. Time of the gentlelady has expired. This concludes todays hearing and thanks to our witnesses for attending. Without objection, all members have five legislative days to submit additional questions for the witnesses and additional materials for the record. Without objection, the hearing is adjourned. [inaudible conversations] [inaudible conversations] the white house announced steps to do with across the u. S. It includes 2. 5 million to regional coordinators to oversee was once a 15 state that are hard hit by heroin addiction most of the northeast. Therell be two coordinators for each of those states. Want to do with the health aspect and another coordinator to work with local law enforced. He was really into computers and scifi and not push a and then hed always heard about Silicon Valley and dreamed of getting to america. From a very young age, that is when the time to do it at 17 he ran away from home in that it. In Silicon Valley today he is seen as the next figure. Various bits of them like that for sure. Hes got this attention to detail. He pushes his workers really hard. Circus at the same kind of idea although delong has a lot to prove. But ive taken away as he is the guy who gets these thousands of engineers, kind of the brightest of the bright and is very hardworking individuals and really is able to get products out of band that can be commercialized and really change the industry if you look at to me he is the guy who has combined software and hardware, the idea of atoms and bits in a way that nobody else has. The idea behind the cities tour is is to take the programming or American History television and booktv on the road beyond the beltway to produce pieces that are more visual, that provide a window into the cities make viewers would normally go to that also have rich history and a rich literary scene as well. A lot of people have heard the history of the big cities like new york, l. A. , chicago. What about albany, new york. What is the history of them . Weve been to over 75 cities. Most of our programming this event coverage. These are not event coverage is. They are shorter. They take you someplace. Key entry into the city is the cable operator who then contacts the city. And i said its the cable industry up there. They are looking for great characters. You want your viewers to identify with the people that we are talking about. Its a program where we take people on the road to places where they can patch things come to see things i learned about not just the local history because the local history plays into the national story. Somebody is watching us. They should be enticing enough that they could get the idea of the story but also realize that this is in our backyard. Lets go see it. We want viewers to get a sense that i know that plays just from watching one of her pieces. A cspan mission as we do with all of our coverage bleeds into what we do out on the road. Youve got to communicate the message about the network in order to do this job. Its got one thing we wanted it today which is built relationships with the city in our Cable Partners and gather some great programming for American History tv. Medicare and medicaid turned 50 this year. Next, former heads of the agency oversees the programs. Nancyann min deparle and gail wilensky. This is part of a daylong look at the history of the current medicaid hosted by the aspen institute. Lbj president ial library and robert wood johnson. This is about 45 minutes. [inaudible conversations] [inaudible conversations] our final panel for today as i mentioned earlier shaping the future of what weve learned and where we are headed. Medicare and medicaid in 2065. It gives me great pleasure to introduce ginning english, president of aarp from a giant nonprofit and Nonpartisan Organization with the membership of more than 37 million. Janine is from california where she was a Founding Partner of a Government Relations firm and previously served as executive director for the Bipartisan Commission on California State Government Organization and economy. Please join me in welcoming janine english. [applause] thank you very much. I like the idea of this panel. What weve learned where we are headed as that conversation brings meaning to this 50 year anniversary. This is the perfect time to take stock of the incredibly important programs and really think about the future. Medicare and medicaid have shown for many years that our country can deliver on the promise of Affordable Health care which is really an asic need for everyone. But we know these programs face challenges, especially as the boomer generation get older. We need them to stay financially sound. But americans also are counting on medicare and medicaid to continue fulfilling this vital mission. It is essential that we discuss responsible ways to keep these programs strong an effect is. Ways that dont harm individuals who need that help here. This panel is a reminder that medicare and medicaid have benefited from leadership on both sides of the aisle. They have grown and evolved with bipartisan support. Aarp believes that an inclusive policy debate, one that recognizes how important programs are to families all over this country will lead to the best possible future for medicaid and medicare. So i am really looking forward to this discussion in but our distinguished panelists have to say. We are very fortunate to have our moderator, jackie judd. You know her from her board when a career in journalism. Many are she was a star at Abc Television news or she reported for world news tonight, nightline, primetime live and good morning america. You may not know jackie also specialized in health care. After her television career, she moved on to the Kaiser Family foundation where she served as Vice President and executive producer of multimedia. So i am delighted to turn over the program to jackie and leave this conversation in her capable hands. Thank you. [applause] good morning, everyone. I am delighted to be a part of this rich conversation and be joined in the conversation with nancyann min deparle and gail wilensky. I will make a bold prediction that Everybody Knows there has read and also published in your brochure so i will not go into great detail. I want to contribute a little bit of history to the first panel that got us going when i was at the Kaiser Family foundation, we decided to produce a documentary to mark the 40th anniversary of medicare and medicaid and i had the great treats and privilege of interviewing the ama president referred to in his name is jack or edward n. S. I interviewed him in 2004. He was 90 or 91 at that point. He was spry and dynamic [inaudible] that medicare was going to create what he called a socialist deal around doctors next across america. He was very passionate about it. He is now deceased, but it was a treat to see him. To make the point that passions run high about these programs. Even today, 50 years later. Part of the political passions we have seen played out [inaudible] with a background in journalism i can ignore the headline of the day. Yesterday the Senate Passed a dock six. The exercise we all go through maybe finish. I would like to turn to both of you to ask for a quick analysis of what you think of the legislation that was passed. I think it is a terrific accomplishment. Virginia reflecting on the role of the ama and the passage of medicare and medicaid with respect to the socalled dock six reform of the way medicare paid physicians. The ama and the leadership was instrumental in working for the past decade on the reform package. I think its very good and will help to strengthen medicare and will have spillover effects in a positive way moving towards paying positions for the value they add to the health care system. I have a particularly pleasurable response to the passage of this legislation because i was the administrator on hand for the relative values guy was first implemented and also saw the 25th anniversary celebration of medicare and medicaid. Facing a time a better strategy than ever used previously in terms of using what was found in the insurance world, the usual customary fee schedule. In fact, what we have seen over time is focusing on various volume is a service to go which is inherent on the scale with a spending limit laid on top of it , both pushed physicians and helpful directions and not being rewarded or encouraged or sometimes even easily allowed to focus on the best clinical outcomes in the most efficiency. An engaged in the worst form of corrective guild because this spending grew too fast, all fees for position and all services were uniformly reduce. It was just inherently unfair. Most of Time Congress to intervene before the writ was take a fact and stop it. The uncertainty caused so much frustration that ama was focusing way too much time on the sgr fixes a policy person. They focus on the bigger issues. Unlike the ama when medicare was passed, i found ama very helpful in explaining out reach for the relative size scale when it was introduced. Im sure this will be a much happier time for them to finally move it away from the spending by the sgr. Many more things to come now. Its always important to bring it back to the beneficiary side. What impact will the toxics have on beneficiaries . Is there cautious and involved . What impact it will have his beneficiaries know they have stable assistant now for physicians and will encourage physician to look more broadly at their care and providing Preventive Care and the things they need as opposed to worrying at and near whether their pay will get cut depending how the nations gdp performs. It should also give them and all of us real encouragement on a bipartisan basis pretty overwhelming that congress was able to get together on the issue and find common ground. Thats an important part of history at medicare over the years. Different things have been tried for trying to advance health policy. Sometimes they work, sometimes they dont. Congress and administration have been able to get together and work on the next iteration and next solution. Other than not having to hear physicians be distressed about the potential reduction of 21 in fees, which pours i think they knew wasnt going to happen. Beneficiaries shouldnt be directly directed. As best we can tell, Health Care Professionals have tried hard to do the right thing for their patients all along. You have physicians for small units of service. A lot of talk about how we wanted to increase value and improve clinical outcomes and encourage efficiency. They really push them and the direction. Most of our professionals ignored those incentives inherent in the fee schedule with the spending limit and did as best they could to write names. I would hear so often both running medicare and then i chaired the Payment Advisory Commission for three or four years of having physicians say you guys make it so hard for us to take care of patients the way we would like to, trying to spend some time talking to them if they have diabetes or other chronic diseases. And not feeling we are pushed financially to do things as opposed to taking care of the best outcome. There are a lot of issues we will still have two resolve. Updates will come up at how much more physicians should be paid and what accounts for about a day than what counts for penalties. There is a lot of work. Nanyann and i will be visiting for many years to calm. The step back from the headline and take a longer view. The pace of change in both of these programs has so accelerated over the past decade nancyann, under your watch. The Payment Schemes and i would ask each of you, what in this pioneering novels do you see that has legs for the next 10 or 20 years . Thats fundamentally addresses the Critical Issues we are facing. Well, i cant help to say we are celebrating the 50th anniversary thinking about my grandmother who was one of the first beneficiaries of the six to seven when medicare was passed. Sitting at her Kitchen Table in tennessee she had a box of her pills on the table as she was talking about whether medicare would help her and i think it definitely has. As we look towards the future is important to remember the stories. For me it is my grandmother, for other people at someone else in the family. Its important to remember the stories and look at the future and where its going to always hope the best about medicare provides, a stable affordable system of health insurance. My grandmother that to be 98 and im convinced one reason is because she didnt have to worry about Health Care Costs and also afforded her family members he ability to not worry. So that is huge. Whatever we do, we need to keep that in mind. Alluding to the neoprograms being developed now unimplemented around the country to try and move towards a more teambased care, towards what is population caring for a group of patients try to help them get better, showing outcomes as opposed to feeforservice all a card Payment System in the past. Manicured and its plans are rolling in part because that is part of what they offer to medicaid. I think those are models that show a lot of promise. The great news is not only our hospitals and physicians and other Health Care Providers not a part of them, they are working to take them to the next level. Private inspector insurers are doing the same thing. Let me try to explain about what the new model is and what i think we know in dont know. There is an effort with cms, center for medicare and Medicaid Services trying to encourage groups to come in and put bundles of pavements together. Family hospitals are physicians, hospitals post acute care, home care or is dealt nursing facilities. Sometimes all of the above together. To see whether or not this improves you, that is the clinical outcome to the patient and also reduces cost. There are these Accountable Care organizations which are kind of a baby step towards a more integrated Delivery System to make in an physicians and that havent worked together to agree to combine services and efforts at akin shows and saving and the quality metrics. Then we get to share the savings with medicare. One thing recognizes the Pilot Projects we try, try it before you roll it out to all 44, 46 million seniors are voluntary. That means a big cell selection bias. The groups that come in to try it may be the most innovative, the most entrepreneurial, the most organized. And probably the least frail. And well, whether populations are more or less frail can be measured. There are risk adjustments. They are not bad, but they are not perfect. The question is if we were to adopt this for the country for providers on medicare would do the same. The answer is that its hard to tell hamas to expand successful ones and see whether they can be scaled up. One of the big surprises i have found is a former researcher instat bulwarks in the small doesnt always work in the big. You might have a Pilot Project work really well in a few areas of one state. When you try to replicate it and see what happens if you try it in a state. Sometimes it just doesnt work the same and it may be the cell selection and trying it on a lot of faces introduces problems you didnt anticipate. We have to make sure it is producing better clinical outcomes at lower class can be scaled and replicated and we have to really drive that. Im a little jaundiced about whether we are going to find things that work and then nothing happens. Maybe because i lived through what was a very successful project is paid a single amount for hearts offer placement of bypass surgery. I worked really hard to get this off the ground. Much harder than i thought i would have to. I would say lets get this done and it would have been. If he meant later it actually have been and i was yelling and screaming all the way there. By the time tree and to stir not, she was supportive, expanded and continued and died away. We have to really drive these changes because while we are seeing a slowdown now, im sure well talk about it, it is not clear what is causing the slowdown whether it will continue and with all the baby boomers that the financing challenge even in the highly unlikely event was a god into the future. We will really have to take advantage of these initial success is to really know. Back in the day i was there for the 35th anniversary of medicare and advocate and you were there for the 25th. Back in our day when he did a demonstration program, it was just that. Small, very contained usually. Demonstrations authorized for medicare are very widescale. As many as a huge percentage, 10 or more have access so we are going to know sooner rather than later whether they were. Secondly if they do work, if they are able to control costs and also increase quality, the secretary has the ability to roll them out nationwide. That is not something the secretary had when you and i were running medicare. I think that within the law because congress realized we really want to see if some of these rings were and encourage the private sector to change because why would you have an incentive if you thought it would be like the one i did before and it would be a few years and then put everything back where it was. I think it sends a signal to the private sector as well. And the satellite at acs are struggling. As i said, i think it is finally to see what the people who havent been working together to Work Together. A lot of the socalled pioneer ceos willing to take risks of loss and gain, and number had dropped out in some of the one and a gentler version are struggling. This is not a criticism. They are trying something new. If you dont have carriers you are trying to write thing. Driving this change will be important. Part of it is lessons learned. I ask you building on what gale said about her frustration of seeing success in cnet fell off. What lessons did you learn in government about when you see success they make it stick and grow and go to the next. One example is the scary one. The demonstrations that were quite small geographically contained that were successful. And then they would die. I think an experience i had taught me and president johnson could have told me to make a successful it needs to be more than one persons congressional district. You need to have not just the senator from virginia but the senator from texas and the senator from idaho invested in looking at the success, seeing life helping medicare and hoping to strategize how to expand it. Thats one thing i learned. We cant have a conversation about medicare without talking about the baby boomers. I think i heard last night that enrollment in 2030 will be doubled from what it was in the year 2000. Mindboggling statistics. How does the system absorb all of it and what are the financial science we need to look for that this can be paid for in contained . You will be an interesting trajectory. Somebody asked me the question then i went and bought. It not a linear increase. We are going to go to 78 million or so on medicare by the time we get to 2030. One result, not hard to imagine these are the people who were born between 46 and 49. All those fellas at that time came back from world war ii had time to say hi, honey and started having babies. And then there is a lovely novel and then there is another that occurred in the late 50s, early 60s im not quite sure about. It means that we are going to feel the financial effects of this rash of 10,000 people sign up today starting in january 2011. That is the phrase i have heard. It will put a pressure on how services are provided. I just spent almost the last two years on Clinical Education Committee for the institute of medicine and i have a lot of concerned about what we have the right mix of physicians. But we have the right mix of physicians and Nurse Practitioners and other nurses and can we get them to practice in teams and be ready to take care of chronic care. We will both have challenges in terms of who is coming into medicare and the numbers. The financial challenge is going to be a lot of the general revenue side almost half of medicare spending comes at a general revenue. We tend to think about it as the wage tax that finances hospital care and some of the nursing home care. It is actually almost as much coming out of general revenues. My guess is sometime around the end of this decade, maybe 28 teams, we will see financial pressure coming on board as the first wave. The good news is they seem to be healthier people coming in and we have to be careful not to project the experience of two or three decades ago of people who are 65 to 70, how help they were, what kind of health Care Services they use because many of the people who are aging now are healthier than their predecessors. The team that appeared to be likely to get around a long time. The other end will have a lot more of weather is not kindly called the old will people who are above 85. And so it will be financing, but the actual provision of care and figuring how to take care of chronic care populations with the help care system that is still very much focused on acute care
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