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tv   Politics and Public Policy Today  CSPAN  October 15, 2015 5:00pm-7:01pm EDT

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caring people i've ever met, i spent 40 years in this career, people, let's face it, you're not going to get rich with what you do. you do it because you love what you do, because you love the people you're working with and because you're always struggling to get them help. federal agencies ought to pay attention and get outside the beltway and hear from people what we need to be doing as providers. >> thank you. we just have about a minute left. quick question from this side. >> unfortunately it's kind of loaded. good morning, mr. murphy. thank you. neat information. i'm the executive director of the june associations in wshlz washington, d.c., how does your bill address the need for cross cultural staff to ensure culturally competent care with the culturally and linguistic service standards? >> it's already required? >> different states have passed i believe eight -- >> are you saying that that's already required? >> that's what i'm trying to explain. >> okay. >> i think it's eight states it
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is mandated. i think 13 it's on the table. and a couple have vetoed it. >> what states individually do is up to them but certainly along those lines we recognize that's valuable. and are you saying that it's a federal regulation? >> i'm not familiar with the process. i'm just learning. >> okay. because the extent that those are out there, what we're doing is we're trying to pick up the slack for a lot of failed federal agencies that haven't paid attention to that. i think it's extremely valuable to have so we want to make sure there's more access to providers who are minority members and being part of communities and being out there. as we have made major changes from our first draft of this bill 3717 to the current one 2646, and we're working on other things there, too. we recognize that's a valuable part of a necessary change that people do have that cross-cultural sensitivity to help. we want to do that. if you have other wording on language to help us with that, we're glad to look at that. >> thank you. >> thank you very much.
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we really appreciate your time and for being here and engaging in a beneficial conversation. >> thank you. i hope america will speak up. >> thank you so much. >> please welcome the honorable chris murphy member of the u.s. senate committee on held, education, labor and pensions. >> well, thank you very much to national journal and jansen f m pharmaceuticals for having me here today. i got to listen to tim murphy's presentation. read once a thousand-page history of our homeland ireland. and i kept on waiting for the
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murphys to show up in this history to talk about all their great deeds and i flipped finally to the index and found out that in a thousand-page history of ireland there's only one single murphy that shows up anywhere in it. and so we like to think that we waited to do our good deeds until we came to america. but it's great to be here with tim who has been a wonderful partner in this effort. and thank you to all of you for a really fantastic turnout this morning. we feel both in the house but particularly in the senate given that we've had a little bit later start on taking this issue seriously, that there is momentum in a new way behind attacking the behavioral health crisis in this country and i'll maybe finish my remarks by talking a little bit about the political context and some of the thorny questions about how to talk about mental health in the context of these mass
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shootings. but what we know is that this has been a crisis for a very, very long time. and it's nothing new for families who have been dealing with it for a long, long time as well. for all of us, this is a personal issue. for tim this is a personal issue because it's been his livelihood, his profession. for many of the rest of us, this is personal because we've watched close family members try to navigate a system that simply doesn't work. i often say that my family has a long, proud history of mental illness and i say that because we talk about it in my family, not unlike we talk about our cuts and bruises and scrapes and our broken bones and our predisposition to heart disease, we talk about the fact that we also have a history of behavioral health in our family. and we've been lucky enough to have the resources and the capacity to navigate through a
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very complex system, but we know in my family that others don't and that's really what this piece of legislation is about, to finally give answers to these families who feel like they hit brick wall after brick wall. you know, when we set up the community mental health system in the 1960s, it was one of president kennedy's signature pieces of legislation, it was call a bold new approach at the time. and it was. this was our effort to close down what were at that time called insane asylums and move people with mental illness out of institutions and into the community. and it was the right thing to do. but over the intervening 50 years, we've encountered two major problems with that bold new approach. the first is, is that we never properly resourced the community
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care necessary to properly care for the people that left these institutions, and as you know what happened is that many of them didn't get served and died. others got reinstitutionalized in emergency rooms or prisons. we just didn't keep that promise as we often say in connecticut in the wake of that community mental health reform. but the second thing that happened is that by virtue of our concern for setting up a new community mental health system, we ended up compartmentalizing mental health and behavioral health walled away from the rest of our health care system. we all see it today. we have community health care clinics that we're proud of, that we invest in. but as we increasingly understand how the entirety of the body works together, and frankly as we increasingly understand that by treating
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mental illness in a wholly different physical space with a wholly different reimbursement system, with a wholly different set of insurance rules, we really perpetuate that stigma. so, the legislation that we have introduced, myself and senator cassidy in the senate and tim murphy and eddie bernice johnson and others. it certainly is about building new capacity. we've got some major medicaid reforms here, which is going to attack the diminution of 4,000 in-patient mental health beds since 2007. it's going to allow for more people to be able to see primary care and behavioral health clinicians on the same day. but it's also about trying to bring these two systems together. i'm particularly proud of a program in our bill, the mental health reform act of 2015, that would provide grants to states to try to break down the
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existing regulatory barriers to the coordination of physical and mental health. what i hear about in connecticut is that community mental health clinics and community primary care clinics want to collaborate, but because states regulate them wholly differently they have a hard time working together. even harder time collocating. so, our legislation really is designed not only to add capacity, but also to try to get these two systems working together. and we hope that by doing that we're attacking this stigma, that we're not just making the system work better, but we're bringing the system together as well. but we also hope that there are other parts of our bill that attack that stigma. we take the next step in parody in the senate bill by forcing insurance companies to disclose what all of their bureaucratic hurdles are to the guarantee of parity that we passed several years ago. we give the administration new enforcement powers to actually
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make real that guarantee which has been illusory for far too many. we attack the discriminatory treatment in the way that research is done by setting up a new research organization that will specifically focus on best practices for the delivery of mental health and start challenging our colleagues to put money into that kind of research just like we're putting it into other types of research at nih and cdc. and i tell you, we are hopeful that there is serious momentum behind this bill in the senate. we only introduced it right before the august break, myself and senator cassidy, but already we have five republican co-sponsors and five democratic co-sponsors this week. we just added our new pair, and next week we'll likely announce another pair. i'll be honest, we actually have a longer line right now of republicans than we do democrats waiting to get on this legislation which is wonderful
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to have as a problem. and we feel like with a hearing scheduled in the health committee later this month, the first hearing in the health committee on mental health in three years, that's amazing to think about, that we're poised to move this bill. as my time is up before i sit down, let me just spend two minutes talking about the context of messaging here. i know that wore talking about this in a more robust way because of these shootings. but i went to the floor yesterday to challenge my colleagues to understand that the mental health system, the behavioral health system, has to be fixed because it's broken, period, stop. and that we shouldn't fool ourselves that we are going to cure the nation's epidemic of gun violence by fixing a broken mental health system. why? because the united states has a gun violence rate that is 20 times that of all of our other
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competitor oecd nations and yet there's absolutely no evidence that we're spending less money on behavioral health or that we have any greater rate of mental illness in this country. there's something different about the united states. but it's not necessarily in our behavioral health system. i don't deny that if you fix some of the gaps in our behavioral health system, it will have a downward pressure on violence, but we have to be very careful over the coming weeks and months of debate of falling into the trap, which tries to define america's growing gun violence epidemic as one that is rooted in a behavioral health system. i don't mind conflating the two because i think that it will ultimately help to make our behavioral health system better and if this is our opportunity and our moment to try to pass something, then we'd be fools no the to take it. but ultimately we're not going to fix the gun violence epidemic in this country if we don't get serious about what
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differentiates ourselves from other countries, and this is not the forum to talk about that, but it isn't necessarily a question surrounding our behavioral health system and how we fix it. thank you very much for having me. i look forward to the debate. >> please welcome back lauren fox staff correspondent at "national journal." >> thank you so much for joining us today. i wanted to start out with the bipartisan nature of this bill obviously a rarity in washington, d.c. can you take us a little bit behind the scenes of how this issue became so bipartisan, what's it's been like to work with congressman murphy and others, senator cassidy in the senate. >> so, i give a lot of credit to tim, tim's a good friend. he really set a precedent for bipartisan cooperation in the house by building this robust
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group of republican and democratic co-sponsors. when i decided to really dive into this issue at a new level at the beginning of this year, i decided that the most likely vehicle that was ultimately going to become a law was going to -- was going to be the one that had the biggest amount of bipartisan support in the house, so i went to tim and said, listen, i don't know that i agree with everything in your bill and i don't know that i'm going to guarantee that i'll introduce a carbon copy, but let's try to do companion bills that have the same foundation with maybe some differentering branches that come off of them. bill cassidy was very involved in tim's bill in the house and somebody said to me actually early on, you should go talk to bill cassidy about this because he would walk into tim murphy's hearings with a dog eared copy of the book "crazy" which many of you have read and is a guidepost for a lot of us who care about this issue. so i approached him and he
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immediately said that he wanted to dive in along with me. we spent a long time working on the draft of the bill. it is largely a companion bill on the house measure, but we've got some things that are different. a little bit more focused on prevention, for instance, a little bit more focus on coordination. and i have been very pleasantly surprised at how fast our colleagues have signed on. we immediately rolled out the bill with myself and senator stabenow and senator franken who on our side have done the most work on mental health, on his side it was him and senator collins and senator vitter and then we've added since then senator capito on their side and senator murkowski i think will add more very quickly. i think what this will become is a bill that has a bipartisan support but a bipartisan support that is sort of a cross-section of ideologies in both groups and
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that will be an important signal to leadership. >> i want to give you an opportunity, you addressed this at the end of your speech just now but we've often talked about mental health legislation in the context of the gun debate and there always seems to be more discussion and momentum after a tragedy occurs. does that stigmaize mental illness? >> i think this is an incredibly important topic and i've talked very openly with my colleagues especially on the democratic side of the aisle how we talk about this. what we know is there's no inherent connection between mental illness and violence, that people with mental illness are ten times, 20 times more likely to be the victims of violence than the perpetrators of it and we do risk perpetuating this stigma and we see it play out in really disturbingly open and blatant ways today. remember the germanwings plane
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that went down in europe? remember the conversation that was openly playing out on major cable news networks after that? that someone with a history of depression shouldn't be allowed to fly a plane because somehow there's a connection between depression and a desire to take down a plane in an act of mass murder? that's ridiculous, but it shows how easy people make this connection between even -- between mental illness and a predilection to violence. it doesn't mean that we should forsake the opportunity that's been put in front of us to bring this bill to the floor but it's why yesterday i went down to the floor and gave a specific speech calling out my colleagues and saying if you really want to take on gun violence, then you have to take on the celebratory culture of guns in this country. you have to accept the fact that what makes us different from other nations is not the amount of money we spend on behavioral health, we can do much better. what makes us different is the fact that when people have a dispute in this nation, when
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people are dealing with internal demons, they go reach for a shotgun to try to settle their disputes. that's not what happens in other countries. and i think it's important to add some lines of clear distinction as this debate goes forward. >> i want to talk a little bit about your bill and what it does to help identify and help young people who are diagnosed with mental illness. obviously getting to individuals earlier can be very helpful in their treatment long term. >> so, we've got a very specific program in this bill which would engage and invest in early intervention, so our bill starts the program at 3 years of age but we've actually heard a lot of feedback, i've done 11 or 12 roundtables in connecticut and one of the things we heard loud and clear was we should actually move it to zero. early intervention programs that really identify individuals who are showing those warning signs
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of mental illness, serious mental illness, and get them resources and get their parents resources up front. the bill continues to make down payments on things like mental health first aid which is a program of early identification by people who are watching kids, day care providers, teachers, social service personnel so that we can find the kids and get them into treatment. and then, again, it's just a matter of building capacity. i really believe one of the most important things in this bill is this ability to see a primary-care provider and then on the same day be able to see a mental health clinician because a lot of these kids are coming in to see pediatricians but then when they get that referral to a behavioral health provider, either they can't find someone or the logistics of getting to them just become too big for families that have a lot of economic and social challenges. and so collocation of primary care and behavioral health which
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will be made easier under this bill i think will get a lot of kids who are already seeing their primary care physician pretty regularly into behavioral health treatment. >> i wanted to talk just a little bit more. your bill calls for an hhs assistant secretary for mental health. symbolically what does that say about how it changes american's view of mental health issues? and also, you know, logistically, what does a new role do? does it create sort of organization? or are there fears it could create more bureaucracy? >> so, you know, this is a subtle but maybe important point of distinction between the house and the senate bill. we keep samhsa intact in our bill. we certainly think that there are ways that we can reform samhsa, but we don't think it's necessarily productive for it and its leadership to be eliminated. we do, though, parrot tim's bill
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by setting up this new assistant secreta secretary. here's where we're coming from, what's frustrating is most all of the serious conversation and debate about mental health and substance abuse is happening within samhsa which is controlling a tiny portion of the federal government spend on mental health, behavioral health and substance abuse. most all of the money that's being spent on that programming is happening within medicare and medicaid, and yet there's no sitting next to the secretary who is thinking creatively about how you use medicare and medicaid in order to advance new treatment models in behavioral health. pecori which is the new comparative research center set up under the health care law, is actually doing more work in behavioral health research than they are on any other sector of research. they said it was unexpected for them, but they just found this giant lack of research in the best behavioral health practice
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models and are trying to fill it. but if there's not somebody in the secretary's office who is translating what a group like that is coming up with and making sure that it is infused we're really not getting the biggest bang for our buck. samhsa's important, but you have to have somebody who is overseeing the big mental health spend, not just the targeted dollars that are going through samhsa to states. >> how do we ensure that insurers are following through with the changes made in the affordable care act? is there more that can be done there to ensure parity? >> they're not following through. they're not. we hear on a daily bay sisis th insurers have taken the issue of parity and erect so many barriers to getting that behavioral health benefit that it just becomes meaningless often and the stories are
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heartbreaking that we get. you know, one of the things i'm struck by is that when you walk into an emergency room in connecticut, and you've got, you know, a broken leg or, you know, a bleeding ulcer, you get treatment immediately. right? but if you walk in with a complex behavioral health issue, let me correct that. when you walk in at night, when you walk in at night with a physical illness, you get immediately treated. when you walk in at night with a behavioral health diagnosis, you sit in the hospital until 8:00 or 9:00 next morning, nobody touches you, nobody treats you, nobody evaluates you. why? because they won't touch you until they know they can get somebody on the phone with the insurance company to get you the authorization for treatment so they warehouse you overnight. physical health doesn't require that prior authorization, you can diagnose and treat immediately. for some reason the brain requires pre-authorization. what we need to do is do what this bill does, had is shed lights on the processes that the
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insurance companies use to try to deny treatment and then give new enforcement mechanisms to the federal government to go after companies that are violating the law by essentially doing an end-around with these bureaucratic hurdles. >> i want to give the audience a chance to line up questions. those are going to start in about three minutes. are there local or state programs that you view as leaders on this issue? you've started digging in, have you discovered things that you thought to yourself, wow, this is a great idea and something we should be doing on a federal level? >> i think both our bills in the house and the senate are infused with work that we've learned from state governments. programming specifically designed to do early interventions on schizophrenia, for instance, our state programs that are now funded in this bill. we have wonderful but simple program in connecticut and it's in a couple other states as well that invests in telemedicine
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that allows for primary care physicians who encounter a patient with a complex behavioral health diagnosis to call up immediately a behavioral health clinician who will do an immediate in-person phone consult while the patient is in the office, so rather than have to send them across town to the behavioral health clinic, you can get an immediate conversation on the phone. we're doing that in connecticut, and it's getting rave reviews and really good outcomes. so, we pilot programmed that in this legislation as well. so, you know, we really do believe that a lot of the innovation starts at the state level in the house and the senate bill both i think involve a number of programs that come from the grass roots. >> even though one in five adults is diagnosed with some kind of mental illness each year, the number of psychiatric beds has decreased dramatically by 14% in recent years.
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do you view that as one of the biggest barriers of care? where do you sort of rank that in terms of ensuring that people get the care that they need? >> yeah, i mean, that's -- that's at the top of the list. i guess i haven't gone through the trouble of ranking all of the terrible problems that we have in our behavioral health system. that would be far too depressing. but, yeah, that's at the top of the list. because, you know, what's happening is that people are just sitting in emergency rooms for days and days and days, but there also, then, is created a pressure on the back end where -- by the people who are in the institutions are being pushed out before they're ready and we just hear that story over and over again in connecticut. a woman who has become very close to me tells a story about her son who committed suicide the day after discharge from the hospital and she begged for him to stay. not clear whether it was the hospital pushing him out to make room or the insurance company
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pushing him out because they didn't want to pay but his mother knew he was not ready to come home, that he was not stabilized, but when you lost 4,000 beds since 2007 there's just, you know, only so many places that you can go. and, listen, this is going to be the challenge. let's be honest about our two bills. our two bills make two major changes. they get rid of the inb exclusions so you can start building in-patient capacity again and then they allow for the same-day rule to go by the wayside. you know, those are going to cost money. and, you know, we have got to make the case to our colleagues that you cannot fix this problem if you resource it at the level that it is today, and in this budget environment that's very, very difficult, but it's not going to be enough just to rearrange the deck chairs. you got to actually make some serious investments. that's not going to be easy, but tim and i and bill and the
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others working on this are committed to it. >> i want to just make sure that it's time for audience questions, that people who haven't already asked a question get the opportunity to, so if you've already asked a question -- >> he cut me off. >> i'm sorry, i think we just need to make sure that there's new voices in the discussion. >> he didn't answer my question, murphy cut me off before i could ask my question. >> very briefly can you ask your question. >> i may. i just am looking at the very first line of murphy's law or proposal and you started talking about stigma as well, all right, and he quoted violence 10% of untreated psychiatric disorders result in some sort of violence. and you're concerned about stigma. well, here i quote the very first line -- >> can you ask your question, please? >> untreated serious mental illness in recent acts of mass
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violence. so, the very first line of that immediately connects violence with those who have psychiatric diagnosis. >> so, yeah, i think i spoke to this, you know, and very intentionally, you know, i think this is amongst the most important questions we have, how do we acknowledge that we are talking about behavioral health reform in part because of these episodes of mass violence without perpetuating and creating this stigma, so, again, i've been very outspoken on this matter. we should fix our behavioral health system because it is broken. full stop. and it doesn't mean that we should forsake the opportunity to fix the behavioral health system, but it's very -- it's very dangerous if we talk about this in the wrong way. >> thank you.
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go ahead. >> how are you doing today? can you hear me? my name is jennifer hoff. my son matthew -- thank you so much. i'm here from orange county, california, i'm a family member of one of the 4% and as a member of the 4% our voices aren't generally shared because our family members are too sick to speak up for themselves. they're not well enough to find their way here today to advocate against civil commitment reform out of fear mongering because they fear they will get locked up because they're homeless under a bridge. so, they're too sick to advocate for themselves so we have to come here to advocate for them. so my question would be, what are you doing to address the needs of the 4%, those who lack insight, like my son, who was institutionalized from ages 12 to 18 because he tnt respodidn' to the current medical treatment?
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there was no brick walls for our family financially nor in our roll low de ro rolodex, without eliminating or divolving samhsa, families like us don't see the money being spent differently, so simply increasing funding would not necessarily mean funding going in the right direction. our families are not represented in data pools from samhsa. you will not find my son as a failure on anyone's pretty pie chart. my son has found his peer group now in state prison because that's where they all end up when they turn 18, graduate from their facility, get a plane ticket and their shoelaces and go back home to our communities upon which there are no wrap-around services for people like my son because they choose
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not to participate in services because they're not sick. >> i'm sorry -- >> so the question is how is your bill going to address the needs of the population upon which we don't even know how many exist because no ones tr o tracking them until they wind up incarcerated. he walked into a bank pretending to be isis off his meds or he'd blow the place up. >> thank you. >> he doesn't have meds. it's a known population. how are we addressing those voices? how are we representing those families and how are we looking out for the families of the monster, the families of -- >> thank you. i'm sorry. thank you.éu >> so, it's a big -- oatit's a question, right? [ inaudible ] >> these tragedies are not a surprise from our vantage point. they're not a surprise. >> yeah. >> we're not trying to connect violence to all mental illness,
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but i'm going to tell you right now, i've been screaming for 17 years for help. >> sorry. >> so, it's a known population we're dealing with and how are we dealing with -- >> i know we got a long line here, so let me just try to answer it. one, you've got to empower parents and families to be more involved and current hipaa laws don't allow that especially when your child becomes of majority age. you're all of a sudden cut out of the decision-making process and so both of our bills include changes to hipaa laws to allow parents to be more involved. second, when i go around and talk to my behavioral health community i ask one simple question, i say for the really complex behavioral health kids, who is in charge? and everybody looks at each other and nobody really has an answer, right? some people say, well, the schools, you know, social workers in charge and some people say the primary care physician's in charge and some people say the community health physician is in charge. we've got to answer that
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question and my belief is that you build the coordinated systems and you change the way that you pay for health care so that you're requiring systems to coordinate across -- across each other and to get paid based on how healthy they keep people rather than how sick they keep people. they will solve some of those questions of leadership. and so, no, listen, i -- the reason that tim and i are doing this is for the people like your son, right? that's the reason that we've decided to dedicate our legislative lives to trying to fix this. and i'm sure we don't have all of the answers, probably not even 25% of the answers in this bill, but we're trying. >> thank you so much. do we have another question? >> yes, senator murphy, my question is if the imd exclusion is lifted or partially lift ed, probably effectively completely lifted, and the money will go --
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some of the money will go to state psychiatric hospitals, but there is no -- is there a requirement that the states that then divert their medicaid match to help pay for that hospitalization maintained funding for medicaid services and community mental health system? because the state funding for mental health is only back to where it was before the recession. >> right. most all of these expansions of federal dollars include a a minute maintenance of effort provision. i'll double-check with our bill. that's our intent. that you're not stealing from peter to pay paul. >> i'm not aware it's in your bill. >> we'd be glad to look at that and follow-up? >> do we have more questions on either side? no. i have just one more for you, senator.
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i wanted to talk a little bit more about when you're talking about this issue of mental health, obviously there are a lot of stories and a lot of people who are very passionate about this. do you find in your conversations that that sort of mobilizes you, keeps you going, ensures that you can go to leadership and say i think this is worthy of getting floor time? and are you optimistic that this bill will move forward out of committee? >> to be honest, i think it goes both ways. i think the reason why we've grown this very quick, robust, bipartisan list of support is because the issue is personal, because, you know, i imagine that every single person that signed on to this bill is doing it in part because they intellectually understand the challenges that are confronted by the people in this audience, but they also have a personal story as well. but i'll be very candid with you, the deeper i get into this issue and the more time that i spend with families, the more
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complicated the solutions become to me. you know, i started out by saying that my family just sort of thinks about behavioral health in the same way that we think about physical health and that's the way that we have attacked the stigma is to say that the two are identical. but they aren't. mental illness is often wrapped up inside trauma in a way that complicates and compounds it. and it's got to challenge us to think differently about how you address the underlying issues. you know, if you have a broken leg, you really can just put a cast on it and it will be better. but if you have a complicated behavioral health illness, it may not be that you just need to treat that individually. you may also need to treat the support system around that individual. you may have to reach out to the parents of a child or the siblings and talk about some of the issues that have compounded
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the behavioral health issue by surrounding trauma. i remember going to our biggest in-patient psych unit for kids in connecticut, and they had about 16 kids that day in the unit, and i asked the director, i said, well, how many of these kids also have trauma histories. this was a behavioral health unit. he looked at me and said, well, all 16 of them have trauma histories. i guess it certainly inspires me every time i hear a story to do better. but it's also made me understand that you are going to have to approach this new holistic system we're building in a slightly different way than you might approach a physical health or primary care system. you've got to challenge the system to have the resources to reach out and treat those around and help those around the individual, not just target the individual. >> congress is obviously working on this in a bipartisan way. is the white house engaged on
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this issue? have you been talking with them at all about sort of the prospects of a mental health bill? >> you know, the white house has been engaged. i would love for them to be more engaged frankly. and so we've clearly been working with hhs and with samhsa on our proposal as has tim. i'm not sure yet who's going to be testifying at our hearing in the health committee later this month, but i imagine the administration will be there. you know, secretary burrwell is serious about this issue. obviously she is very, very bold in her reform proposals for how hhs and cms reimburse for health care, and we just want to make sure as they're building this new model of rewarding outcomes rather than rewarding volume, that they are also doing that for the behavioral health system. understanding that in the behavioral health system there is frankly a greater connection
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between the volume of practice and the quality than there may be in other parts of the health care system that really one of the things that we are lacking in the behavioral health arena is the volume, is just enough visits is enough beds. and so we want to make sure that this payment delivery system reform is really thinking about the unique way in which it has to encompass the behavioral health system. >> i want to thank you for all of your time, senator. i really appreciate it. i think it was a productive conversation. >> thank you very much. >> thank you. ♪ >> please welcome dr. rene binder, president of the american psychiatric association, kathleen nolan, director of state and policy programs at the national association of medicaid directors, john snook, executive director of the treatment advocacy center, mary gilberti,
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executive director of the national alliance on mental illness and dr. fred osher, director of health systems services policy at the council of state governments and justice center. >> good morning. i want to thank you all for joining us today. and i'm hoping that we sort of have a lively and exciting discussion here on stage. i've told the panelists, i hope you all kind of interact with each other. i have a couple of questions for you each individually, but please feel free to weigh in as we kind of talk about this. obviously there are a lot of perspectives and voices on this issue and we want to make sure that they're all represented here. i want to start with dr. binder. i wanted to ask you to address this issue of parity. i think that this has come up a couple of times with both senator and congressman murphy. and is there a better way to address this? what do you view as the way to ensure that insurers are being
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fair about the way that they treat mental illness compared to physical ailments? >> so parity for mental illness is the law right now, but unfortunately it is not always the case. and there needs to be better enforcement of parity. the problem is that the people who are not getting parity are often people who cannot advocate for themselves. and one of the things, for example, at the american psychiatric association is doing is we have developed educational materials. we have developed posters. we are asking every psychiatrist and every clinic to have this poster up in the clinic. the poster says "you are entitled to coverage for your mental health care in the same way that you are entitled to coverage for your physical care. if you are not getting this
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coverage, then this is what you need to do. this is the number to call. this is how you take care of it. so, we need to let people know what they can do when they don't have parity. >> okay. yeah, go ahead, please. >> did a report last year where we asked our members what they were experiencing with respect to parity, and they were finding that denials for medical necessity in mental health were twice as much as for physical health care. the networks, we've heard a lot about that, were completely inadequate, people couldn't get access to care and the big concern about medications and having access to the full array of medications under these plans. we found a lot of problems when we went out and talked to our members about parity enforcement. >> this is obviously a burden for someone who is already dealing with mental illness to report issues of parity, it's bureaucratic i assume and difficult to get through. >> very. >> i wanted to also ask john
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snook, the treatment advocacy center focuses on eliminating barriers to mental health. what do you see as the biggest obstacles keeping individuals from getting care in your experience? >> sure. i think one of the biggest and you've heard it discussed already today is just the idea that we haven't kept our treatment laws up with the science. and so we have a situation now where everybody in this room realizes that if you have a severe mental illness and you're in treatment you're no more likely to be dangerous than anyone else. but at the same time we have treatment laws that say you can't get help unless you're a danger to yourself or someone else. so, what that means is if you're a person who is ill, who needs care, you're left to your own devices until you get so sick you're actively violent to yourself or someone else and that's not how we treat any other illness and i'm so excited that senator murphy, congressman murphy, are really taking steps to say we need to change this. >> i wanted to kind of going off of that, is there a way to
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intervene earlier? and what have you all seen in terms of successful programs that intervene much earlier? >> i think there are any number of ways that we see working in the states and that's one of the nice pieces of these bills is they allow states to step in and take those sort of next steps to make sure that people get the care they need before they're a danger, before they're sick. and what the reality shows is that if you treat people before they're at this level of crisis, it's cheaper, it's more effective, and people do recover. >> if i could add to that. >> yeah. >> i think coming from the medicaid perspective, one of the things they're really working hard on is what we call integration of physical and behavioral health. i think one of the opportunities that comes from that is being able to find people before they're in a crisis, to have regular sources of care that don't just consider your physical health outputs and your physical health status, but
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actually are better able to spot issues that may have behavioral health ramifications or symptoms. so, by bringing the previous speaker talked about collocation. am some of those ideas where you're trying to think about the whole person actually can do better at spotting things early than when we're only classifying you as needing a behavioral health when you're in that office and seeing those individual providers. >> yeah. go ahead. >> yeah, there are a lot of early intervention programs and, you're right, early intervention is very important. so, there are programs in the states which target people, young people who might be developing early signs of schizophrenia. so, an adolescent or young adult whose thinking is maybe a little bit off, maybe they're not tracking information, maybe they have some unusual ideas, so they can be brought to a
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psychiatrist, and the psychiatrist will do a come p e comprehensive evaluation to try to determine are these early signs of psychosis and of schizophrenia and if they are, they are very effective programs to get these young adults into treatment very, very quickly and to try and prevent full-blown schizophrenia. schools to try and identify children who have early problems. there's a program called typical or troubled had targ ed which t teachers which are often the first people to notice. so, the teacher will wonder, is this typical behavior of an adolescent or is this an early sign of some problems. and then they're not supposed to do the evaluation. they're not qualified to do the evaluation. but they identify it, and then they can refer the young person to a mental health professional,
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to a psychiatrist to do a detailed evaluation and say does this young person need additional intervention and maybe hopefully we can prevent future problems. >> go ahead. >> also wanted to wholly support the notion of prevention as a thrust of our community mental health systems. i wanted to just address the next step. we can't always tell or predict when an individual does have a mental health crisis and that it really is incumbent upon all of our communities to have a robust crisis urgent care capacity. those people in need in the middle of the night on a weekend can easily access care that can help address their significant mental health symptoms at that point in time. far too often without those alternatives we see the path of least resistance being to take that individual to a local county jail which is not the place where people should be that don't pose a threat to public safety. >> yeah. >> i think fred's exactly right.
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you have too many situations right now, and i think the imd exclusion goes very far to fix that. in many communities what you have is doctors triageing and saying, well, this person's sick and needs care, but he's probably not going to hurt anybody tonight, so we're sending him home because we need that bed for somebody who is even more ill and that's just a terrible way to treat people. >> yeah. >> imagine if you're family. you are lost, you have no options to care for your loved ones and you're worried they're going to be the next headline. it's a terrible way to do things. >> dr. osher, i wanted to piggyback on that, the issue of people with mental illness who end up in the criminal justice system, you've done a lot of research on that. what can local law enforcement to understand the population or preemptively work with them or once people are in the system create programs that make it easier or, you know, less traumatizing? >> yeah, so that nexus between
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behavioral health and criminal justice is one which is really important for us to explore, just as i applaud the bipartisan approach to senator murphy and representative murphy have taken to mental health reform issue, so, too, do we need collaboration across the behavioral health and criminal justice spectrum. with regards to law enforcement, we have about almost 2 million people each year with mental illness that are in our jails, in our prisons, many of whom don't pose risks to public safety. what we have seen is law enforcement agencies around the country developing specialized police-based responses, the most common of which is a crisis intervention team in which those officers learn about mental illness, learn how to deescalate situations when they encounter them in the field and then are given alternatives to incarceration for those individuals who then seek that care. it's really an important component of an overall strategy to reduce the prevalence of
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mental illness within our jails which are filled with individuals with mental illness four to eight times rates of mental illness in our general population. every county around the country is struggling with this national initiative, the justice center, and there are psychiatric association foundations, the national association for mental illness, nami, and they need to come together to say the status quo is not acceptable. we need to bring them to scale, and drive the problems to be fixed in jails. >> add nami, there are a lot of programs that you guys advocate for individuals. do you believe they have access to the care or do they even have knowledge that it exists? could there be more done to expose mental illness and what are the barriers to the care? >> sure, we take calls every
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year, people don't know where to go for help. they often have no idea if the crisis services are in the communities. most often they believe they have to choose between the police and no care. so it is absolutely the issue of no knowledge, but then there is not sufficient service there. i can't tell you how many times i try to help people find help, and it's not covered by insurance, it's a big problem that people experience, beds are not available, there is nowhere for people to go. so it's a knowledge problem and it's also an access problem. we say we want people to have early, easy, effective access to care. lots of times you get care and there is no evidence that it is going to help you, we know what works but people can't get it. >> i want to address the issue of sort of rural communities and care and centers. what can we do for individuals
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who do not live within 20, 30, even a custom hours from mental health care centers? >> well, i can jump in here, in the medicaid space we've -- i think there used to be a bias that face to face was so important. and the only way to deliver these types of services. and we are increasingly in both the physical and behavioral health support, using technology as a way to help. so psychiatrics, that sort of line, are ways people are trying to tap into and get the care in their communities. that is really the most important access that we have. and access in your communities and being able to continue your care in your communities. so we have a couple of things like telepsychiatry. and there are ways to support the individual in the community, and community providers. we have a couple of examples of states who are really trying to
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-- essentially use the -- vermont uses the hub and spoke model where you have a center of excellence that may treat people in crisis or do some interventions but then helps work with the community providers when that individual returns to the community. so those types of model that support the individual in the community and the providers in the community and to care for them and to maintain their continuity is important. >> i want to ask you what you see as maybe some of the shortcomings of the legislation and how can the community help to expand coverage? >> so i think some of the shortcomings are, i'll set aside the access, because if it is not there people are really struggling. but one that has come up the most frequently that is a barrier is the exclusion of imd, the general information, and the
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community and audience hear about what it is since it has come up a few times. but the issue that that leads for us is that there is sometimes a need to have individuals in what would be called an institution for a short period of time. but we drop them out of the system of medicaid when we do that right now. with the imd exclusion we can't keep them in a continuity of care and environment if they need admission to one of the imd facilities. so what is really important is we have to be able to include imds in our systems of care. but not to flip the switch. we are not looking to warehouse people and put them back in the hospital. but that exclusion of that facility type, or in some of those facilities, some, our continuity of care is really a challenge to take care of people. so bottom line, the imd exclusion is one of the biggest barriers for us in really
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getting to a stronger system of caring for people's behavioral health. >> thank you, we have all sort of talked about mental health courts. i want you all to sort of weigh in on what you have seen, whether they work and whether they need to be at a larger scale in order to be more effective. what have you all seen? >> the mental health courts are very effective and appropriate for certain cases. the way that it works is that a person who has committed a crime and they have mental illness is approached by the public defender. and the public defender says you have a choice right now. i'm your defense attorney and i will defend you but we know you did the crime. and we know you're going to stay in jail or go to prison. but you have an opportunity here. i can go to the d.a. and i can try and make your case that you
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need mental health services. but you're going to have to participate in it and we're going to have to go to the judge and say that this is appropriate for you and the services involve medication, seeing your therapist, substance abuse treatment. it may involve housing and if you are willing we can keep you out of jail. and you will no longer be a defendant, we will change your title to a client right now. and it is very effective. i have done a couple of studies on behavioral health courts in san francisco. and what it shows is that people who participate in mental health courts, in behavioral health courts, if you follow them over a period of time. if you compare them to similar kinds of people who have committed the same sorts of crimes, have the same mental illness and do not participate in mental health courts, there
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is a decrease of incidents of violence and crimes and a decrease in jail time. so that is really an effective way of getting people out of the criminal justice system and into treatment. >> and certainly i support mental health courts and especially courts as a tool, within our too long box and really appreciate the doctor's work in this area. it is the case that they tend to be in scope. and the number of clients and participants are relatively small. for those selected clients it's a really important opportunity to get connected to care and move forward in their recovery. it also is an opportunity for the judiciary to learn more about the needs of defendants with mental illness, the smallness makes it a tool, not a solution. and then another component, they are dependent on an effective,
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robust, mental health system. so at the core what we're talking about today is improving the mental health responses, so that they can work effectively, including mental health resources. >> we have to recognize that the existence of mental health courts is that the acknowledgment that mental health services fail when we have to arrest somebody to get treatment. so patients like ait, the out patient treatment is a mental health court without having to be arrested. and we're talking about states not using it, having it on the books but not doing the work to have it effectively implemented. for too long we've allowed the system to say well, he is a difficult patient.
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he is going to be too expensive and difficult to work with. well, let the jail work with him. and that is about it. >> we have time for a couple of questions to discuss these issues. i want to talk just about not just access to care but are there enough doctors and trained professionals to deal with you know, clients? . >> many of these bills introduced in congress, one of them, the psychiatric association supports, where there are solutions in terms of increasing the work force. and it's absolutely necessary that we may never have enough
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psychiatrics. and that is where we get into the kinds of programs such as tele psychiatry, so if the expert is not available in the community they can do an evaluation long distance, in rural areas for patients who are disabled orderly and can't come to the psychiatric's office. >> i think the benefit for medicaid when there is a shortage we have the hardest time competing for those providers. we frequently don't pay as much. we often have people who could be considered more difficult to deal with. they don't come in. so we have a very hard time when there is a shortage, it doubles down on our most vulnerable people who need the services most. so even when there is a psychiatric available in the area we often have a time making space for medicaid patients to
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see them. >> families call that a license to hunt. meaning you have to hunt for care, you can't get it. >> the reimbursement for medicaid is very low. in my community, i live and practice in san francisco. the psychiatrists say that for patients who are medicaid, it costs them more to provide the service than for reimbursement. something needs to be done about that. if we expect the psychiatrics and other experts to see the medicaid patients. >> i want to start in the last part, you can feel free to address questions or submit them to the panel. >> yes, we just became a co-sponsor of mr. murphy's bill. so very excited about that and feel like that helps on the front end to be able to get people into care so they don't commit crimes and end up in
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jail. but the criminal justice reform that is going on right now, all the discussion presents a great opportunity for anybody to do something like this. and having reviewed a number of the bills, i don't think we're quite doing enough. we have things like you know, studies and things that would encourage more mental health courts. but i'm not sure there is a big enough carrot or stick there that would address what happened last week with the young man in virginia, et cetera. would you all have ideas respecting federalism to some degree, not bigfooting totally, but doing better than we are with some of the proposals, how we can encourage states to prioritize making sure that these folks don't end up in
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jail? >> well, very important topic, thank you very much for the work that you do. as i mentioned earlier, this is an area of bipartisan reform, these conversations going on, very heartening to think about these conversations as we think about the role of the prison systems and what role they play in keeping communities safe. i will highlight the bill in congress right now, the comprehensive collaboration act which does fund along the time of c -- the type of continuum, and the bipartisan support that is there, senator franken and cornyn introduced the bill. i think these are federal incentives for people around the country to develop responses. >> thank you. >> no questions on this side,
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we'll go back to the last. >> my name is bernie aarons, i'm a psychiatrist, a medical director of a large psychiatric hospital. i used to work in samsa. i am thinking about the two speakers we heard earlier and trying to cross-reference the special education and mental health work that these people do. you raised two areas that need attention, crisis intervention teams, mental health services in jails and prisons. opportunities for expansion and training of the mental health work force. and i'm wondering whether attention -- whether the attention to federal legislation helps accelerate the implementation of those programs or diverts our attention in a way that makes it -- that may prolong that. i wonder, for example, if attention to how the
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bureaucratic boxes are structured in the federal government is where efforts should be spent or somewhere else. i would be interested in your thoughts on whether you find the federal legislation helpful in the advocacy and professional work you do or a diversion in some ways that we need to be worried about. >> thank you. >> i think i can tell you pretty clearly that having a senator not only know what imd stands for but to talk about it on the stage is amazing. to have congressman murphy go county to county and talking about fixing samsa and fixing the mental health system is amazing. i think -- we have never had as an exciting time as we have right now. this momentum to finally reform the mental health system. if this is a problem i would love to have more of them. >> and i just want to add that i think the efforts are complimentary, you mentioned cit, there are federal bills to add some resources there but we
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also work at the state level at nami trying to get statewide assistance at the technical programs trying to build them up. i think the federal level only compliments at the state level as well and tries to provide a catalyst for that. i see the efforts locally and statewide and nationally only help. the work that we're doing on capitol hill, we held a briefing on capitol hill to talk about that. i think they're very co complementary. >> there is innovation and that tells us how our country works. we innovative at the state and local level. we invest the dollars on where it can invest. wherever the federal structure is, we have to keep that living. it can't be a single solution but it does come out in different ways. there are different types of work in different communities.
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whether it's urban or different types of places or communities. so as we continue the conversation at the federal level, which is vital from the federal level, we have to continue to find the great examples at the state and local level and share them to drive that innovation. >> if we think about it, the republicans and democrats, we have the bill in the house of representatives and a bill in the senate. so people being motivated to work on either side of the aisle, really doing something to highlight, the fact that our system is broken and that we can fix it. we can fix it federally and we can fix it at the state level. so i'm very excited about this. >> thank you, we'll take a question from this side of the
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room, thank you. >> we're with the health committee, i know we talked about easterly intervention, we can talk more about that, the early streaming, the children in school, the physician's office. we learn more about what the kind of screenings may look like. >> thank you. >> do you want to go ahead? >> i was just going to say, we are seeing those types of innovations in medicaid. it takes a little bit of switching because you're not diagnosing something happening, but something that could happen. it's a challenge and so i think we need to be thinking about how do we put people into some of these programs. i also know we talked a lot with children or young adults, the
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clarificati classification is a concern. we have to be cautious how we do this, and when we do it in the health care system that information will travel with the person, it's a dynamic i think we're working on. but it is happening. >> i just want to add that i think some of the word that imh is doing, the adults who are experienci experienci experienci experiencing psychosis, the therapies and the issues, will we be able to finance that going forward? financing it with medicaid or private insurance dollars. it's very different than a regular mental health center. i walked in, and ping pong
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tables, and young adults were cooking and laughing. it has a very different feel to it. that is why it's so successful. they are coming out with data soon on that. that is a really important program for people to focus on. it would be a great service. so if anybody was encountering a very serious chronic condition of the young. >> we'll take one more question. >> very quickly, my son died this year at age 23 of heart failure after a seven-year battle with schizophrenia. i am the director of parents for care in baltimore, maryland. i get phone calls every week, desperate e-mails every week. i can't get my child care, right? we all know that the parody is really the issue and i would say illegal discrimination, or rather illegal discrimination rather than stigma. what i want to notice is,
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parents mention it to me all the time and i used to mention it to john hopkins during treatment. insurance won't keep my child in the hospital? why don't we sue them? why don't we sue for medical parity. i can't think of the lawsuit, the state of california has one going to force parity. what are your thoughts on that? >> i totally agree with you, and the american psychiatric association is actually involved with a lawsuit in california and there is a lawsuit in new york. and being lawsuits can be very, very effective. i'm really sorry to hear about your son, i'm sorry about your loss. i think you raise another good point about the difficulty of medical illness and psychiatric illness. it's another reason for code locating services to work together so when somebody comes in for cardiac problems and
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mental health problems, when somebody comes in for health screening it's not just the study of physical, and the whole mind and body and whole brain. >> these sort of events are so vital. because i think if you talk to a person on the street they would have no idea about things like same-day billing, about the idea you're not able to get physical care the same day you get mental health care. any of these issues we're talking about it's just simply not on people's radars. so the more we can talk about the realities of what you deal with, you hear so often, well, why didn't the family just get him help? having no idea that families have no option and we need more solutions. and this is the best way to do it. bring those issues up and to have these discussions. >> we sue for everything else. >> thank you so much. >> i want to thank our panel for their insights and help. i really appreciate it. thank you so much.
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>> thank you. >> thank you so much to our leaders and panelists today. at this time i would like to invite michelle goodrich to the panel for closing
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condition. our organization remains at the forefront of advancing nervous system treatments and improving care for people with brain disorders. and we will continue to invest in finding innovative treatments and developing solutions and improved patient outcomes. at the same time, we do recognize that these treatments are just one of many to putting people on the path to recovery within the larger ecosystem of patient care. with the larger situations we have been discussing today we think are critical to make sure that patients who are mentally ill will get the chance they deserve to enjoy a better life.
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so early diagnosis from the mental health community are particularly important to reduce costs to patients and their families and to a broader society. so as you have heard today, the collaboration between the mental health and criminal justice system we think is crucial in improving lives for patients in public systems. we really applaud and thank and support legislative efforts to reform our mental health systems and together we believe we can find the best collaborative systems for a win, win situation. so thank you again for being here today and being a part of this very important conversatio conversation. known as the city of good neighborhoods, this weekend, a c-span city's tour joined by
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time warner cable explores the history and literary life, this week, we visit the library for the history. >> the irish were desperate, they came over during the famine, and years after the famine, things were not great. it would take one relative to find out about these great jobs working in the elevators and mills, and then word would go back to ireland do you want to come to buffalo? you won't be rich but you will have steady employment. they came to this neighborhood, called the first ward. it has its name because when buffalo first was created in 1832 as a city it was divided into five political wards.
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and this area along the waterfront, along the buffalo river has always been the first ward? >> on american history tv on september 6th, 1901, president william mckinley was assassinated. we'll discover the history of the buffalo waterfront and how it adapted from the nation's grain center to modern redevelopment. >> right now we're at fire city, this is a collection of the grain bins in the buffalo area originally owned by different companies. it's over on ohio street, it is re-generated for many different purposes, for art, music, history tours, we take people around the grain elevators and tell people about this history. there are poetry readings, all sorts of different readings from
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this historic file. >> see all of our programs from buffalo, saturday at 6:00 p.m. eastern on c-span tv. and sunday afternoon at 2:00 on american history tv on c-span 3. the c-span city's tour working with our cable affiliates and visiting cities across the country. next, a look at the potential benefits and drawbacks of the transatlantic trade or ttip. financial times world trade editor shawn donnan opened the conversation. this is about an hour and 40 minute
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minutes. well, good morning, everybody. >> good morning, dan. >> we're going to get started. i think we owe it to you since we started this conference so early in the morning we should not delay. welcome to the cato institute, i'm dan ikens, welcome to our long gestating conversation. which is called, will the transatlantic trade partnership live up to its promise. on behalf of my colleagues, i want to thank you for choosing your time on this most festive of holidays. excellent group of experts, they sort of span the ideological
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spectrum, so you will get a lot of different perspectives on a lot of different matters. it's been quite a week for the trade policy with the implementation of ttip. it's been quite a year for trade policy. in 15 years since i've been at cato, we'll see where it all leads. the ttip has long been presumed to be here depending on the conclusion of the ttip and succession of the ttip, steps have been taken so we're about to embark on a really robust debate about the ttip. the debate has been going on in europe. i think the europeans are a bit frustrated that the american negotiators and the american public have been a little bit sidetracked or focused on other issues. but i think people are ready for
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this. it's -- ready to start talking about this. there are actually 345 people registered to attend this conference. i guess some of them have slept in. but they will be here at some point during the day, i hope. also as evidence of the importance of this issue, c-span is here, and c-span can be broadcast and is live today and recording. so if any of you plan to leave early i just want you to know in advance that your boss and your colleagues will know. they will see it. they will find out. please stick with us. so the work that ttip has done and the debate that is about to happen we wanted to sort of lay on the table, what are the issues? there are a lot. this is complex, we want to talk about some of the traditional trade negotiations that have been put on the table as well as the broader complexities, the geo-politics, what does it mean for the multi lateralism, we'll
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bring it to the front today. some people understand more clearly what the regulatory coherence business is all about. this is said to be the larger games. it doesn't look like a whole lot of progress has been made. or there has been a whole lot of accord how to proceed. so we're going to look at the issues by the end of the day. people ask what are the economic models about. are they important. they have a session on that towards the end of the day as well. but you have the program, the information is available in the lobby. also, the participants in this conference were asked to write essays, and we're publishing approximately 1500. and we have been publishing them on our website. and we will continue to do that through next week.
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next week is the tenth round of ttip negotiations in miami. so we're going to sort of carry this over to that point. just one other tip, if anybody is going to tweet use the hash tag ttip. and people can chime in from all over tell worlhe world, so i wa introduce the person who will set the issue. you all know shawn donnen, he is an excellent journalist and understands the issues keenly. shawn is the world trade editor at the financial times, he did this right in the ft's wheelhouse so he is a perfect
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person to set the table for us. in his capacity as world trade editor, shawn leads the ft's global coverage of trade and development issues and follows the imf. he is such a sport that he got back from peru where the meetings were held, and he is jumping right back into this. so he is very versatile. before assuming his role as world trade correspondent, he was deputy editor and world asia news editor. with a lot of roles he is working his way up to the top. everybody who does trade policy knows shawn and likes to talk to him. and i'm really happy that he is cheer to chat with us. just a couple of other points, besides the financial times, some of the papers he appears
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in, the morning post, l.a. times, christian science monitor. shawn is a graduate of boston university where he has a degree in international relations. yet he still writes very well. i would like you to help me in welcoming shawn to the podium. thank you. >> thanks a lot. i -- i will beg your forgiveness. as dan said i am just off a plane. so if i get my acronyms mixed up and start talking about the imf, or the tax measures that were passed or approved in lima, or start talking about emerging markets you will know that you have the wrong set of notes here. the ttip, for those of you who follow me on twitter you will
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know it's sort of an unhealthy obsession as it is for some of you as well. it's something i have been following the last two years. it clearly is an immense project. i just thought i would -- it's a really interesting time in ttip, because we're in that kind of uncomfortable middle period. i think it's -- we're somewhere just before the half time whistle goes. and i think it's valid. it's a good time to sort of step back and think about where we are. and that is what you're going to do today, really going to be diving down into the issues. i thought i would offer four random thoughts about ttip here, and this is how i think about it. and also the conversations that i have with my editors who constantly say when is this thing going to get done. >> and when will it get done? should -- what should we be
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writing about this? and i think it's -- i'll start with really part one, which is i think it is important to remember and i think that this sometimes gets lost in the discussion of the detail that you know, ttip is still a valid endeavor. it's a big valid endeavor, wortworth stepping back and saying okay, this is a trade relationship that is as important as it gets in the world today. something like that $800 billion worth of trade or more last year. and also it's about the future of trade agreements. and really that issue of regulatory coherence that dan was referencing there. that tangle of regulations that business complains about.
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and in closing with that, those non-tariff barriers that we have been writing about for a long time. i think it's an interesting business, increasingly, this is not a phenomenon over the last year or two, but this is now our transatlantic nowadays, which was once an american corporation or a european corporation, now reaching across the area. i also think -- if i would endeavor, i guess beyond the bilateral transatlantic relationship, think of it in the context of the wto and global trade liberalization efforts, and the ttp.
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i look at the theory of trade, if all of these ftas were in the world and going to complicate the world and create a tangle of noodles, i would like to patent the ravioli theory of trade and that is where we are now in the ravioli, or the dumpling theory of trade. we are seeing a series of agreements that are being written or negotiated and that some day they will become the great lasagna, that is a global multi-lateral deal. again, i'm patenting that. so if you use it, please -- and i think that is a long-term project. i mean, clearly -- when you talk to people in the u.s. administration, part of the reasoning behind the launch of
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ttip and ttp was about getting something happening in the realm of trade liberalization and moving beyond the paralysis you have now. ttip is also a geopolitical agreement, and also that is because of my background in international relations. i think the geopolitics are as valid for politics as ttip. people talk about the concept of china, i think ttip is equally valid in that context particularly with what is happening in russia and ukraine nowadays. these are to me, the three big pillars of the endeavor.
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the question is get from my editors, which is okay, this is big, can you actually get it done or can they actually get it done? if so when. and when you're in the daily news business it sometimes turns into slightly depressing conversations. i think the question -- the answer that i offer my editors nowadays, is yes, it will get done. but probably not any time soon. and know mthat may not be the a that people in business and others who have a shorter horizon of thinking may want to hear. but i do think that increasingly in my mind, it's hard to see this getting done during the obama administration. and that raises all sorts of interesting questions. i think they are trying to get it done.
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clearly they are trying to get it done. there have been agreements on negotiations accelerating. but really, everything has to go incredibly smoothly to get even close. and as one senior official involved told me when we talked after the meeting, recently, really what we're laying out in front of us just gets us to the mid-game. and i think that is something that is important, especially in the context -- and i use ttp as a reference point. ttp for those who cover it, it's been a joke that this thing has been in the end game for two years if ttip is just getting to the mid-game. we have a long road ahead there. there is a couple of reasons why i think this is -- going to struggle to get done in the obama administration. one is the complexity of the
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deal. i think a lot of the conversations feel still like they're only just getting started, even though it's been two years. and i think that is interesting. the other point is, i still think for the u.s. administration, ttp is going to take a lot of energy to get through congress in the next -- to close, to scrub, to get the text out. to sell politically the administration is really going to be focused on that over the next year or so. clearly, the folks at usgr have argued for a -- for a long time that they can walk and chew gum at the same time. but there is a question of political questions as well. you have seen in ttp, there is sort of a building urgency over the last two years.
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for most of the last six to nine months if not year, the ttip negotiators have been meeting weekly, essentially. and in intersessional agreements, they have been on the phone closing agreements, especially the u.s. and japan negotiators have been on the road constantly for most of the last year. so -- i don't see that in ttip right now. i may be missing something but i just don't see that accelerated schedule there. i think the other point is that the political timeline ahead is getting very interesting. i don't think in 2016 ttip is going to draw quite the opposition or the heated debate that ttp is here in the u.s. for obvious reasons. but i'm not sure that in the context of the anti-trade
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rhetoric we're hearing on both sides in both parties right now that even the deal with europe is going to be immune to that or some kind of blowback. you know, there is an argument that putin's new syrian endeavor and his other adventurism in ukraine and so on could help to make that geopolitics case in the congress. but then i keep wondering and i was thinking about this on the plane last night, although not for that long, i wonder what donald trump would make of ttip if ttp is a disaster, what would he think of ttip. and then i came up with some fun quotes that -- sort of imagining him speaking, and then i switched off and moved onto something else. but clearly, there is -- there
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is a potential risk there. but i think 2017 is the more important year in terms of the political timeline. this gets into why i don't think it would get done in the administration as well, with the european politics or here domestically. which is you have three monumental votes in europe, in 2017 and that is the german national election, french presidential election. and i think equally importantly the u.k. referendum on whether or not to be in the -- to remain in the eu, in each of those elections i would expect ttip will be an issue that will be vigorously debated. there were 150,000, 200,000 people in the streets of berlin
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on saturday protesting against ttip. that tells you certainly, people feel strongly about this in germany. angel merkel has been treading very carefully on this. her coalition partner, even more so arguably. but you know across europe there are now 3 million signatures on a petition against ttip. and that is starting to become a big number. i also think that sort of vocal opposition is bleeding into a kind of broader skepticism about ttip that i hear from some of my colleagues who are asking me as europeans, as much as economic journalists, but also hear from others in the quiet center now. and i think that is really -- really important. i also think the leaders in each
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of those elections or votes is politically savvy enough to know that there is a risk for them in this debate. i think the third random thought is that the barriers or stumbling blocks are just not going away. and in fact, they're arguably municipltiple multiply, we talked about the debate, that is still there. the safe harbor decision we saw recently, from the top court in europe, it's not technically part of ttip but it's embl emblemattic in a broader position.
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a combination of jealousy and angst that you see in europe now when is comes to the issue of innovation in technology and companies, which is really interesting and i think will shadow the talks. gmos, the decision earlier by the commission to allow states to opt out of any decision is important to recommendations on the decision. but clearly it tells you a lot about the european commission and how they will handle the politics. the isdf, and i can't believe i have gotten this far without mentioning isdf. the investor state dispute settlement mechanism and all of the heat around that. i think there is a view in brussels that they have come up with a solution of a recent proposal for a wholesale rewriting of the system. i think you only have to look at the u.s. chamber of commerce's incredibly quick response to that -- negative response to
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that proposal to see why that may be more difficult than the europeans think in terms of the negotiations. it has two main points as far as i can tell. the creation of an international court with sitting judges to hear investment cases sounds a lot likely exit to me, a mult multi-lateral institution that will hear the disputes. the europeans want to come up with something entirely fresh. the second is an appellate function for investment cases that would allow governments to go before a panel of sitting judges. i think both sit in very much with this european idea that the answer to a problem is often to set up a new institution. i don't think that goes down so
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well, particularly in places like this. and here in washington, more broadly. i think you know, there is a myriad amount of other questions out there that are building these big questions on whether financial services are included or not. these are things that should have been answered sometime ago i would have thought. that said, i did say yes, i think this is going to happen. and that brings me to my fourth and final point. and that is both sides want it to happen at the political level, certainly. so what has to change for it to happen? and i think that is something that the negotiators on both sides have been thinking about a lot. and were discussing during that recent meeting. i'm not sure they have all the answers but clearly, something has to happen to get some kind
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of new momentum behind ttip. i think the first thing is really a re-calibration of the endeavor. is this the big -- totemic catch-all agreement that a lot of its advocates have thought? should it be that? there were people when i was still based in london who talked about the ttip as the beginning of a transatlantic -- basically a growth of the european union across the atlantic. and it would become a single economy, a single market across the atlantic. i'm not sure that ttip, given the current challenges, will get you there. that may be a good long-term goal. but it's not where this is heading. particularly with what is happening in the eu, and suspicion of the eu with the eu
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itself and its role. so i think that is one point of re-calibration. so do you focus instead on something that focuses on tariff -- service, maybe government procurement line. do you turn the regulation into a longer term project? people have talked about ttip, i think there are two lines that really come to mind with ttip. one was, let's get this done on a single tank of gas. that has gone away, the argument now traps is with an electric car instead of a big gas augugaa -- guzzler. i think they were making this
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point a year ago, there was an early harvest deal to have. and the regulation should be viewed as;5!qx a longer term pr. when i talk or listen or ask questions on regulation it is still striking to me how much the question of regulation on things like food and auto safety. i'm not sure you get things solved in a regulation agreement. i think the acceleration point, right now next week we'll see an exchange of tariff offers, the first one didn't go so well. they first agreed to set in a 97% threshold. so turn this into a negotiation over there. the remaining 3% of sensitive tariff lines.
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so if you're going to go in a closing mode in 2016 you need to meet more quickly than they plan to at this point. to tariff offers next week and procurement offers in february that already takes you into the spring, almost. i think the second point is european leaders need to handle the politics better. and they need to be braver, if they want to get this done. and i haven't seen any signs of that particularly from the european commission, which i think has been a much more political animal than it was before. so i think -- one of my questions, when she took over, i sort of thought of her option ga-- as engaging in the rope a dope
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maneuver. wear them out. i don't think that has worked. we saw that saturday in berlin. i think, and this may be a provocative point. americans need to be better in the context of this negotiation at proving their europeanness. which again, is not a comfortable admission for some parts of the -- the policy here. i've been away for 17 years and just come back, and struck by how much americans changed in a number of ways. and how the traditional narrative on -- our different economies and how we regulate has changed. and i think actually, the vw example is a great one, there ends the narrative that somehow
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europe is greener when it comes to cars. i think food culture chains, the idea is remarkable, that mcdonald's is deciding not to use any antibiotic-treated meat or any hormones in chicken or beef is important. and it's important in the context of ttip because these are exactly the sort of things that european consumers think about when they think about ttip, the same as chicken and chlorine. so i think i'll stop there. i'll let you chew on that idea, on that chicken, if want. or the freedom fries, if you prefer. just to stop with that point, you really have an interesting day ahead of you. and an interesting point in this negotiation. i think this deal is going to
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get done. but i really do think some things have to change in the dynamics for it to get done. thank you. i think dan wanted to introduce the next panel. is he gone now -- is he coming right back? okay. i guess we could exchange jokes -- >> all right, shawn, excellent overview of the issues.
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we're going to get into an exchange here, please take your seat if you're on this panel. come on up. so this session is supposed to go from 9 to about 10 past 10:00. it's going to be a conversation. the original point -- the original idea was to have a bunch of chairs up here like a sunday morning talk show. but i think there were some complications with the number of ear mikes. so it will be more like an academic set-up. so the purpose here is to talk about the issues, there are lots as shawn just gave you a taste. there is a lot of complexity. but i would like for us to be able to debate some of the issues, to at least address some of the issues. there are lots of them. i want you to leave this session with the sense to there are some complicated issues that might be difficult to resolve. maybe it would make sense to
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take them off the table. maybe it would make sense to compromise in some other way. i would like you to have an understanding of some of the major offensive and defensive european side, and get a sense of where things stand going into strategic round of next week. a couple years ago a paper came out by the atlanta council and bertelsman because it identified 28 or so issues on the table. they produced the results of a survey where they asked trade experts on both sides of the atlantic which issues are the most complicated to resolve and which are the most important and they plotted it. their next y axis. the most difficult to achieve and most important to a successful outcome were up in the top right quadrant.
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obviously trade agreements, gmos, sanitary measures. regulatory coherence. we got a whole panel devoted to that later. labor and environmental standards. intellectual property protection. energy expert relations. there are a lot of issues. let me also note that there's a slight programming change you may have noticed. yana dryer had some logistical issues getting across the atlantic. so phil levy who's also on another panel volunteered to help us out. thank you, phil. the way i want to proceed is i want to ask a question. i have 12 questions here but i'm going to ask a question, direct it to one of the panelists. he or she can start with an
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answer. then others can chime in. when it is time to move on i'll ask the next question. first question i have is for frederick. frederick erickson. all of their bios are in your packets. phil levy from the chicago council of global affairs. celeste from if the a fchlt lchlt krchlaflcio, let me start with a question for frederick. what do you consider the most important issues to a successful outcome for the ttp and what do you consider to be the most difficult to solve? >> well, i think it is actually the same issue and sean drew attention to it already in his talk. of considers it is that united states becomes the 29th member of the european union.
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that's the main benefit that's going to come out from this. if you want to show you're increasing european you should take longer holidays. pick up this european social mod model. and please don't take away our agreed cause are far more environmental than ours are. that's the sort of ambition we're going to have for what we're going to go at ttp. let me just say a couple of words on that issue from the viewpoint of thinking perhaps through the economics and the political economy of it all. i'm not sort of desperately happy with this obsession that a lot of people have about estimate being the potential gains and losses of different trade agreements especially by using plain vanilla models that we know aren't really capturing some of the key benefits that come from trade.
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i'm sort of complicixlicomplicc myself. i think ttp itself has to be put in this broader context and that context is largely that we are seeing an end to 25 years of globalization as we knew it, an end to the idea that constant expansion of the principles of economic liberalism is going to deregulate economies and that that sort of deregulation is going to have very strong effects on what happens externally between countries. i have a book that's coming out in a while and i've been sketching a different scenario than right now and that is we move past 20 years of globalization, given that
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globalization was so heavy powered by big and global corporations, into a period which i think is going to be more characterized by global corporatism in the sense that we're seeing a revival for pretty old ideas about linkages between business and governments. we're seeing a revival for dekrimmer to sometimes protective use of regulation. that can manifest itself in anything from sort of towards skepticism towards emergency acquisition deals. ge bidding for french company -- can't remember the name of it right now. sort of how the politics around
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these deals came to be very sensitive and very controversial. we're seeing in today's "financial times" to plug sean's newspaper an interview with the ceo of barclays bank who is making the case for the build-up of a global european champion in investment banking because he feels that american investment banks are getting too competitive. that's the sort of all-time government interference in the economy that we're seeing and it is going to sort of encourage governments and companies to become closer, sometimes creating crony-type relations. that's the context that i see for ttp which sort of translates itself into a new type of it scenario for global trade where trade is going to go far more slowly in the future than it did in the past 25 years. we're going to see reorientation of the structures of trade,
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partly because asia emerging markets have developed to that point in the economy where they begin to integrate much more regionally than they do globally. you see strong amalgamation effects coming into the region which is taking away a lot of the benefits the american and european economy could thrive on for the past 20 years. >> i want to pick up on the point you made earlier about the united states becoming the 29th european state. does anybody else on the panel sort of share that view that the ttp is the completion of columbus' conquest of north america? or are there other perspectives on these issues? what are the big issues? what are the stumbling blocks? >> good morning. if i may add to frederick's excellent remarks, i see it a little bit differently. i see it as not only -- well, i see it as really not being about
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trade but rather about governance. not only competition of governance models among u.s. and eu countries, but also between a western model and a chinese model, or a western model and perhaps an asian model. and i make that distinction because i think they're not the same. but it seems to me that when we're talking about new issues, such as regulatory coherence, and new sectors such as information flows, that's really much more than trade. and it's -- to me it is about governance when the united states moves from focusing on specific human rights such as labor rights, to a broader conception of including human rights. we've learned something from the european model. so it seems to me ttp could set -- if you buy some of the things that policymakers have said about it in terms of
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creating 21st century trade agreements and setting gold standards and building blocks, i think those metaphors are useful and also a little bit scary. but i think we need to be honest about what this really is. >> other thoughts? >> just to jump in there, i don't buy many of these metaphors myself. i think what we are looking at is actually pretty standard type of free trade agreement negotiations -- that it the result of it is going to be a pretty standard type of free trade agreement that we have seen in the past years. top-up with infusions if here and there that hopefully can at least rub some new ground in terms of dealing with more thorny type regulatory issues. but sort of the idea that has been at least initially sold to the public about a 21st century agreement, about creating a sing
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sl market across the atlantic. i simply don't think this is going to happen. that just leads me to my sort of conclusion of what i was going to say which is that i think this is an agreement that at least in europe is going to be won or lost on its capacity to generate more growth, more jobs, that's the politics of it. if you're going to end up with an agreement that has only small benefits to that quest, then i think you're going to see all the other thorny problems and perhaps controversial issues are going to magnify and become far bigger. it is sort of chlorinated chicken or what have you. if you want to go for sort of the big net benefits you need to sort of run with the stream of what you've seen from a lot of estimates that come on potential growth. you need to grow into those sectors that can deliver huge scale benefits by taking aware tariffs andin

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