but then west of the nation there is the new station state of the large green station it uses solar energy is the stone's throw away from the boundary lines and then leaving a the nation is the center to the east if you go north to have the checkpoint there are checkpoints everywhere you go.

and i caught the slightest glimpse which ended soon thereafter. and then finally they said you can go but i asked if i could take a picture. that was far away. kim and i take a picture? they said no. i said why? because the other agent from behind said it is national security zone was not allowed to take that picture. when we moved away he immediately called and made a complaint. he took the agents name and he called the station to make a complaint. i felt like i got a glimpse

of what people are talking about if they talk about all kinds of things that lots of people say that we live in the occupied territory. talking about being tailgated in the homeland security or border virtual vehicles from the back of their cars and people talk about coming onto their property without a warrant and home invasions i interviewed a man who was pulled out of the vehicle and hit with a baton. there is more stories like that. at one town hall meeting recently with the aclu looking into abuses they

asked how many people does been pulled over? and every single person raised their hand. every single one. so for the early 1990's was one thing and hardly a presence but it has changed drastically within 15 or 20 years. that alone is of a glimpse of the kinds of things i looked at the of course, as i said not solely to the southern borderii]ls the interior in south carolina with those kinds of agreements from customs

enforcement how they represent the southern border into the interior i went to the dominican republic and actually formed its own border patrol urging of the united states and illustrating by u.s. border patrol agents and that is the one example of a global phenomenon throughout the entire world through iraq and afghanistan look at southern europe you can save more and more emphasis on the border looking at those market projections there are

so optimistic to see unprecedented growth to see this move at a rapid rate not just the united states but across the world. that is what i try to look at i talked to so many people from agents to police to politicians and undocumented people to hear the stories and get the stories down as vividly as i can. and a gold to the different themes throughout the book. and obviously the book i say this a lot but i read recently any sort of writing is in the percent listening.

so i just put that down. but it is also part of a bigger conversation so hopefully the of book can become a part of that conversation that we all need to have and with that i will shut up in if you have any questions or critiques or any points to raise raise, please feel free but remember we are being recorded. [laughter]

nogales, for example. but a few things about the northern border. the northern border is probably really, really overlooked. really overlooked. if you go back to 2001 u.s.a. patriot act commitment dates patrt that 300% increase of resources and personnel to the northern 3% border. which if you look at the northern border, border patrol agents on the northern border from the pre-2001 until now it's gone from 300 to approximate 3000. went from 300 up at 3,000 so it

is significantly less but the rate of growth of the northern border is higher more border patrol going to the northern border than south one of the classic talk about the 100 myall jurisdiction they could not work kim from the boundary into the interior of the country so that encompasses 100 miles to the south so think of the different cities that encompasses. like detroit or seattle and also along the coast much of michigan is devoured by that jurisdiction so within those

zones that aclu calls to the constitution freeze on which actually the federal agencies or the federal police have extra constitutional powers where for example, the to go to the checkpoints i was mentioning if border patrol have reasonable suspicion you're undocumented course some -- smuggling favorable you over or determined add add a checkpoint to do a visual book into your car or pull apart your car to look if you have contraband so they have powers above and beyond they can go on to property without a warrant

for example. one and classic example is patrick leahy the vermont senior senator he was driving with his license plate says u.s. government or something but he drove into of border patrol checkpoint they asked him to get out of his car he said under whose authority are you asking me this? the agent according to his testimony pointed to his gun and said that is the only authority i need. on the northern border not the permanent checkpoints the alliance of transportation checks that

border patrol agents would get onto trains or buses not people. you interview there and it's as if border patrol is everywhere.

oh, i know somebody, this guy went, he got arrested the other day when is going to work. he was at a bus stop at 4 a.m. in a vehicle, pulled over and asked him for citizenship and then arrested him. or the latino family services center which has a food pantry and english as a second language class. an interview with the director of the community center. she talked about agents staking out the committee center and asking people as they went to the committee center about their citizenship and actually arresting people. should one case she described where person was deported. or sing and have a church down the road in southwest detroit where everyone talks about this one where the border patrol sticks out hispanic language masses and wait for people to come out of the church. i heard similar stories in upstate new york by rochester.

they formed a church watch committee so people from the community would go to church, for spanish-language mass and surround the church on every sunday. in new york they talked about the laundromat. it's 50 miles outside of rochester. and, of course, where is the border, right? water, lake erie. before 2006 there was no border patrol there. they formed a station in 2006 with four agents because there's a ferry service from toronto to rochester. does a ferry service cut off, did they close the border patrol station? no. the actual expanded the number of agents prove the rate of expansion from four to 26. the agents on the northern border worked a lot with the police. wayne county, new york, it's

known for its apple orchards. it brings in about a thousand farm workers, many undocumented farm workers every year. so when you go there and the talk about the laundromat, the checkpoint at the laundromat, it's a new york state troopers checkpoint but with one border patrol vehicle. it is placed there on sundays during harvesting season, the>> data people go and do their laundry. and if the police were to suspect the person did not have proper documents to be in the and united states, you know, you can go visit the men sitting in a green striped car. so your stories like that left and right. more stories like that on the u.s.-canada border than anything so mor about people actually crossing the border but even though udc, there is the technologies, the kind of surveillance towers, a high-powered cameras that you see along the niagara river, you

are seeing more and more of that. t you hear less about border crossings andag more about the kind of laundromat.en you hr leo i don't know who is -- go ahead. >> you mentioned at the beginning that the borderland has become a constitutional free zone, constitution free zone. er lands have become a constitutional freeze alone the constitution freeze on the. it sounds like a laundromat type of situation that they donny need the papers they just do it is that your experience from talking to these people? as far as the treatment.

>> that if they look like they've been not be documented. >> that is interesting because new york state it has to be the 1070 law to obligate the police however they are doing the exact same thing and the state troopers maybe not the 1070 but under operations to guard which they get funds from a department of homeland security then you have the collaboration between police and border control which is called a

force multiplier. you see that a lot. >> how far does that extent? >> with border patrol? 100 miles. into the interior. look at the contours' of the country it covers two-thirds of the population they're obviously not in the york city but they were not there either/or not in rochester. so things could change. >> in 1998 there wasn't any border patrol agents. now you talk about how many there are.

would ensure point? because in 1990 thousands were coming up here. -- think we should have done nothing about it? that we have too many more agents we should not have increased the amount to allow 12 million people to come up here? i don't understand your point. >>. >> one of the interesting things about the shift of policy one of the interesting things is those different operations brought more border patrol and concentration of technology

but this observation by the head of the and naturalization service 1993 and she said looking at operation hold the line in el paso that brought more agents side by side by side by side on the borderline ben brought a lot to all tasso the -- oh pass so the idea with all these agents nobody would cross. then was replicated in arizona then southern texas and there is a reasoning behind this operation that door is split it the it i am paraphrasing but the north

american free trade agreement at least we will have a short-term and a median term search of a of immigration into the united states so we have to put up a more strict enforcement. she was right. look at the post 1994 exodus coming from mexico averaging a baby 1.500,000 -- maybe at one point is that 2 million farmers lost their jobs. this comes from 1996 but 2 million farmers lost their jobs because the impact of the north american free trade agreement that allows

the u.s. agribusiness or archer daniels midland to go into mexico to sell the corn under the price of production and a small farmer cannot compete then after that somebody loses their livelihood then they will look for a place if i lose my job i will look at some place else so that has stirred the pot. >> so you say that's there are more immigrants coming up because we brought more men down there so that stimulated the employ it? mower tel leave this. i would really like to know your answer to that.

>> was trying to explain that. >> you were not doing that. you were way off the question. i just want the answer. >> let me talk. >> you interrupted him. >> what would you do to stop them from coming? >> i think i was on the track. you asked the way it is looked at now the way it is building up to build up false in to put more agents on the boundary line to stop people who were losing their jobs may not be the most logical. but the question about immigration is not addressed in a holistic manner. >> it is a very dangerous world and i don't thank you understand that. >> thank you.

>> on that note. good night. >> number one who does the department of homeland security answer to? >> then is the big question help their now there are incidents the department of homeland security actually investigates the office of inspector general that investigates that and been bigger cases there is a couple of shooting cases people were controlled from the department of justice but the whole idea of accountability was a pretty sharp debate of what was

happening now and there is a report to coming out a couple weeks ago that they identified 800 cases and 97 percent of those, there was no discipline taken of what would be considered some sort of abuse. very few of those were. very few were disciplined. >> i have a statement it may not be a popular position but i grew up in tucson. we went over the border. nobody asks for people from mexico when work then go home. they cannot go home now so they are stuck when they come to work.

i think they would like to go home but they cannot. that is a lot of the problem and perhaps that man did not understand that. >> yes. there has been a lot of studies around the idea people feel that traditionally is cyclical where people come and go back but now there is a lot of talk it is much harder but you hear people don't even go home nfl loved one dies because they are afraid of the journey to come back to the united states. >> i wanted to say i was one

of the people that was pulled over on highway 10 going from the knicks to las angeles for a business meeting from phoenix, arizona pulled over by border patrol before entering california and theh i've never had a situation where i've been pulled over without reason, overseas or anywhere else, only here in arizona. and i don't think people

appreciate, as you put in your book, the state of the border situation here, that these are our freedoms we're talking about here. we can blather about memorial day and the sacrifice that people have made for our freedoms, but in reality we don't have the freedoms we think we do. and why a u.s. citizen would need to be pulled over for no reason at all, questioned briefly about where he was going, glendale california is beyond me. do you have other incidences in your book about people who were just pulled over at random inside the country? >> yeah. i mean, i have incidents in the book like the one i mentioned on the nation, patrick leahy, you know but yeah, that's one of, i

think that's one of the points of the book that we are looking at, we are potentially looking at a broader civil liberties issue. and as expansion continued annually in those hundred mile zone's, a federal agents, homeland security czar allowed to have this kind of extra constitutional powers where you can be pulled over, anyone can be pulled over for whatever reason, was that a checkpoint or -- >> it wasn't a checkpoint. it was strange. there was no vehicle there, no camera to record. >> you were just pulled over randomly. >> pulled over at a point where, between the borders of the two states, california and arizona. the speed limit goes down so that if you slow down to the proper 25-mile an hour speed limit, someone can waive over safely. and that's what took place. >> so that's, those are the kind of incidents that are becoming

quite commonplace, quite normal actually. >> this took place a few days after the incident of a border security individual being shot on the border, and i felt vaguely as though this was sort of a crackdown on the border, but the border between arizona and california spent border patrol, right? >> it was border patrol. >> it was a border security mission that, it was a border patrol agent pulling over because they thought you were undocumented or smuggling undocumented person, smuggling drugs or you can smuggling contraband or you are a national security risk. those are the three, those are the three coming in, types of reasons. >> based on the years i've lived overseas and studied overseas, i've never seen anything like it. so people think their freedoms are crazy good here.

i have something else to tell them, they are not. >> thank you. do we have time for one more? one more question. >> i had to question. first, is your book the first book that has been written, researched deeply into the subject? >> no. >> have there been other? >> there's other books, there's some really good books out there. ..there are some really good bos out there. operation gatekeeper by joseph nevins or dying to live. border games by peter andre is. timothy dunn wrote about the militarization of the border. from the 70s to the mid-1990s.

there is a lot of books. i think this one is looking at a post-9/11, looking at this kind of rapid expansion, looking at different civil liberties issues and i would like to think that it's you know, it covers new ground but it's definitely on the shoulders of giants as they say. all this great work that's been done around border stuff for years and years and years. >> my other question is has there have been any interest among legislators in your book, in the issues that it has raised specifically from your work? >> beto o'rourke is from el paso. i mean i don't know but i know beto o'rourke he is a congressperson based in el paso, texas and i believe he is pretty

interested in it and we have had some back-and-forth. he is a u.s. congressperson. i know it has reached his year now his desk or his ears and i imagine because he actually communicates with me about it, i imagine that hopefully, hopefully it's been seen by other congresspeople as well. >> none of our congresspeople? >> none who have contacted me. but i don't know. [laughter] >> c-span2's booktv this weekend. friday night at eight eastern with books on marriage equality, the obamas versus the clintons and the autobiography of marion

barry jr. with. saturday bob woodward interviews john dean on the watergate scandal, and sunday afternoon at five annie marks -- anthony marks shed lights on the library's past, present and future. booktv, television for serious readers. >> we want to hear from you. tweet us your feedback at twitter.com/booktv. >> the book "migration miracle" examines how religious groups assist immigrants from mexico and central america and how faith inspires them to make the journey north. booktv interviewed the author, a professor at the university of north carolina. this is a half hour. >> host: unc professor jacqueline maria hagen. what's this picture on the coffer of your new -- cover of your newest book, "migration

miracle." >> guest: it's a cross. and it's a cross on top of a mountain, and the mountain is situated along the u.s./mexico border. and it's symbolic of the many migrants who have died in their attempts to cross the border into the united states, doing so without papers, without authorization. and as we though from, as you may know and the media's told us, the numbers of fatalities, of migrant fatalities are increasing, and i think this year there are 400 depths incurred to central americans and mexicans crossing into the united states. so that cross symbolizes their crossing experience, and the title of the book, "migration miracle," is basically taken from the words of the migrants who often described their successful journey as a miracle. >> host: how did those 400 die? what were the causes?

>> guest: the causes range from being killed by a smuggler to suffocating in the back of a car to asphyxiation to drowning in the all american canal or in the gulf of mexico. many die in the deserts. not, you know, not being able to reach food or water, being left behind. not really -- i mean, many of the migrants who travel here without papers are uncertain about their journey, and so it's organized increasingly by multiple coyotes, and it's become much more organized. and it's much more difficult for migrants to rely, for example, on a single person that they may know who has migration experience to take them across the border. so as the borders become heavily militarized and there's been more campaigns along the border

to prevent migration, it means that my grants have had to find -- migrants have had to find more dangerous ways, basically, to reach the united states and rely increasingly on organized trafficking to get here. >> host: professor hagen, is there an average cost that these my grants are paying to get across the border? >> guest: yes, and it's skyrocketed. if you're on the mexican side of the u.s. border and maybe in one of the border cities, it might cost you $8 or $900. but if you're traveling from a small ham let in the highlands of guatemala, it could be upwards of $8,000, and it often involves then having your family's home put on hold and ransom. so there's an enormous amount of money. and most of it's paid up front, some of it. well, half of it's paid up front

in most cases and then half upon arrival. and throughout that time the coyote carries all the papers that would document that person like passports, birth certificates, etc. so they're really at the mercy of the persons bringing them. now, many good coyotes or smugglers, but there's also many unscrupulous smugglers. so it's a mixed bag there because i have many stories from migrants who smugglers came across them and found them in the desert and helped them. and then other cases where they were told that they were left behind. >> host: how much time have you spent on the border in your work? >> guest: oh, gosh. i've been doing my field work for "migration miracle" since 2009. but i spent time on the border before that because the project that really motivated this was a study on death on the border, and it was about trying to enumerate for the first time the actual fatalities that occur to

migrants. so i'd visited a number of coroners' offices and worked, talked to religious leaders along the border and hospitality homes or safehouses to get an idea of what was going on. and that kind of motivated this larger project, was to understand how they manage and survive and place meaning on the migration journey itself. >> host: did you meet with chi gloats. >> guest: yes, i met with coyotes. but not -- i met with the coyotes when i had to go pick up some migrants at a safehouse, and the -- i had to bring extra money so that they could be released. so often what you find is a situation where you arrive at a safehouse, and then they call a family member in the states and ask for additional funds even though they've paid the amount. and in this case, i knew the

young man personally. and so then i was able to secure the funds and able to go meet with them and the coyotes. >> host: "migration miracle," one of the first things you say is that this is organized into six parts. leave taking, dangerous journey, churches crossing the border, miracle in the desert and la promesa. what is leaf taking? >> guest: leaf taking is the first stage of the migration process, the decision making that goes into whether or not to leave and if -- when the decision is made to leave, when to leave. so it's about thinking about the cost of the migration, it's about leaving one's family, one's community, all that one holds dear. and in most of the migrants in my study, they leave because

they have no alternative. and it's a very difficult choice. many of these migrants had never even been to the capital city or a large city in their own countries, but they were migrating across thousands of miles and multiple fortified borders. so leave taking is about decision making, making that decision. and often, excuse me, migrants will turn to family, of course, to discuss leave taking, and it's often a household strategy migration to send one member of the family up to earn wages to send back to southern the family left behind -- to support the family left behind. but my grants also increasingly turn to religion both at a personal and institutional level. it's basically religion is the institution that they trust. it's the one institution they can identify with mostly. and it's expressed in numerous

ways. but often and very often through counseling and blessings. so one of the interesting findings across all the groups in the study and all of the different religious faiths was, in fact, this reliance on my duration blessings -- migration blessings before they left. they found them very powerful. almost an unofficial passport, a spiritual passport. something that carries so much significance for the migrant themselves. so that's about leave taking. >> host: when these young people -- and most are young people -- in guatemala, mexico, wherever, mostly male? >> guest: no, we -- no. increasingly more and more women are coming. >> host: solo? >> guest: and that's not surprising. solo, i've met a lot of women

coming solo. i can recall one instance it was in the border town right on the border of mexico where i encountered a young woman with her baby, baby must have been about 1, maybe 2 years of age, and she was praying in a church to the black christ which is a very important religious icon in guatemala -- well, it's the patron of guatemala. and when i talked to her, she was praying to locate someone to travel with her across the border. because she recognized it was too dangerous to travel alone. so, yes, increasingly women some of them coming to join their husbands, some of them coming for work. most of the time the women are going to be escorted by coyotes and do not attempt the travel alone, and if a family has savings prepared for the migration journey, their more

like -- they're more likely to provide them to the woman because of the dangers, the extra dangers she might face such as rape or -- >> host: what are their impressions or what do they think the u.s. is like? during this stage? >> guest: i don't think they think of it as the american dream as they did when i started my migration research maybe 20 years ago which was a common expression. i think now they recognize that there's serious risks, and in many of the interviews they're thinking more about the journey, the fear of the undertaking, the leaving, the possibility they might not ever see their family again is very real. and so that's, i think, what has really changed since -- especially after 9/11 with the buildup at the border, that it's becoming so dangerous that religion has taken on an

increasingly important role. and so that, you know, when we used to think about understanding international migration and undocumented migration, scholars have long relied on economic and social explanations. and i think that reflects the types of questions they ask. so if you ask a migrant why did you leave or why are you coming to the states, they will tell you for economic reasons. but if you ask them why are they going to philadelphia versus washington, d.c., they're going because they have family networks. but if you ask them how they survived, how they made sense of the experience, how they managed to leave community and family, they will respond with god's help, with faith. and so that's really been the -- this book is about the unexplored role of institutional and personal religion. >> host: and here is chapter three of your book: churches crossing borders. what does that mean?

>> guest: yeah. the theme of churches crossing borders is about the growth of a new sanctuary movement. we think about old sanctuary, we think about the central american salvadorans who fellowed in the '80s and came and saw -- who fled in the '80s and came and saw sanctuaries and churches in the united states. we have an informal network of religious organizations and churches that have stretched from guatemala through southern united states that care about, that serve my grants by providing them shelter, food, blessings, counsel. but also advocate on their behalf. so among the religious leaders and churches in central america and -- it's increasingly in the united states -- they've become very public, as we know, about the immigration, about

immigration matters. and they're very concerned about the dangers that migrants face in crossing the borders. and for many religious leaders my grants have a right to migrate, to feed their family. so is this is about defending that right and providing them with a safe journey. so that's churches crossing borders. >> host: do the churches have an opinion on the fact that president obama's administration has had more deportations than any other -- >> guest: yes. >> host: -- administration? >> guest: yes. that's basically denying the rights from the church's perspective. yes. now, my understanding is obama meets regularly with church leaders. i know he's met regularly with protestant leaders, catholic leaders, the bishops' conference. the argument from the religious perspective's argument is that the policies are not humane,

they're not fair. migrants aren't treated fairly. the state has the right the deport somebody, but it's often the way it is done, like family separation, somebody picked up at a worksite, and their children are left at home, and those children are put into foster care. and that's another increasingly important phenomenon. these separated families. so i think the churches' concerns are the conditions under which they travel, that they are provided with fair treatment, due process. and, you know, if somebody arrives and works and earns citizenship, then they should be provided that opportunity to naturalize and become a citizen. >> host: jacqueline maria hagen, how did you get involved in this work? >> guest: particular project or in migration?

>> host: general. you said you've been doing it for 20 years, studying it for 20 years. >> guest: well, my father was in the foreign service, so i migrated a lot. and my mother's from costa rica, so i spent a lot of time in latin america. >> host: are you fluent in spanish? >> guest: yes. and i enjoy, i love central america, the people, the culture, the food. and i stumble ld into this project. -- stumbled into this project. it was a very interesting experience. i was in the highlands of galt be mall la -- guatemala working on my dissertation, and i met a young pastor who invited many me to what he called a fast, a fast celebration. and we journeyed up mountains. it was a trek that took us several hours. and at the top of this mountain, sacred grounds, was a group of maya women and men sitting on cold stones and deep in prayer.

and in front of them was a evangelical pastor speaking in tongues. and it was at that moment, that experience that i heard migrants, i mean, people stand up and request assistance and god's help with the journey. and i realized there was counseling going on, and that's something very new in latin america. so the clergy's always been there to serve the poor, to meet their needs about jobs or povert, but the migration counseling aspect is new. >> host: another section of your book, "miracles in the desert." >> guest: when churches aren't available, migrants create their own shrines. they bring their own religious companions with them. so in certain areas of the deserts, you will actually see humble shrines created out of stones, out of sticks. some of these are markers of graves, but others are places

they stop to pray. they wear medallions with their saints, they carry holy cards with images of their saints. and those are their companions on the journey: we went under trellises of freeways throughout the border where they had engraved with crude stones, "god help me," "dios." >> host: did you personally sneak across the border? >> guest: no, i didn't. >> host: so you would walk along? >> guest: yes. and i've been to migrant camps where i've seen the artifacts, the objects, the possessions that they're forced to leave right before they cross. >> host: on the mexican side. >> guest: on the mexican side. and there you also see crosses, lots of crosses, prayer bookings. they're told they cannot prescription anything with them at -- bring anything with them at that last statement.

>> host: what's la promesa? >> guest: the promise. if i make it, in return i promise to offer something to god or to my religious icon. and that's expressed in numerous ways. it's expressed upon arrival by going to the closest church you can find. it doesn't matter if you're protestant and you go to catholic church. denomination does not matter, but it's right away giving thanks. it could be, i mean, the extreme case is returning home to provide thanks at some point, the first place that a migrant would come. and they often make that journey without papers as well. it's to go back and give thanks to your icon. it may be by sending tithes to your church at home. in some cases, some really beautiful cases it involved mothers lighting candles, white candles to illuminate the way

for their children, and when their children arrived, they lit a candle and called their mother or father, and then the candle was blown out at the other end. so it was a way of connecting across borders spiritually. >> host: professor hagen, what's the significance of what you've written in "migration miracle"? >> guest: from a theoretical perspective, it's about introducing religion into rational models of migration. it's about recognizing we live in -- the academy has for a very long time treated migration as a total secular process, social, economic process. and i really wanted to bring the human face to the migration picture and try to understand migration through their lived experiences which then took me to faith and to organized religion. there are and it's also -- and

it's also for them. so many -- there's three or four key people that are reintroduced in each chapter. these are women. and i've kept in touch with them, and they have now read this book to their children. >> host: are they all over the u.s.? >> guest: yeah. they're all over the u.s. one is here in north carolina, several in texas, one in new york. >> host: and still illegal or undocumented? >> guest: one is documented, and the first thing she did when she got her papers was fly back to her hometown to give thanks. >> host: and she's back up here now? >> guest: she's back up here now. she's done very well. she and her husband both own businesses, aboveboard. she's very involved in the local church. her children are doing well in school. >> host: professor hagen, what, in all your years of studying migration, what do we not know about it and the effect of it?

in your view? >> guest: i think we don't know enough about the context in which migrants leave, that we don't understand it. we treat it as something so voluntary and do not recognize it's in a desperation often. so i think most of what we study in migration we do so once the migrants have arrived. and so we very -- we really don't understand the context in which they leave and the context in which they travel. when i talk to people about the actual journey, they're amazed. when you talk to people about how many people actually die crossing the border, people are surprised. but i think the academy's concern and policymakers' concern has been with their experience here in the united states and the costs to our economy. rather than looking at the human

side of migration. >> host: have you interviewed the border patrol? >> guest: yeah. >> host: what's your opinion? >> guest: well, it's mixed. interestingly, the migrants interviewed who have been picked up by board or patrol generally speak -- border patrol generally speak very favorably about them. so, you know, i -- when i went and interviewed them, many of them felt that this wasn't the job that they thought it was going to be. and that it's an impossible job. it is impossible. i mean, how can you -- you'd have to have every border patrol agent standing, you know, hand to hand along the border to really control the border. and they recognize that it's led to increased crime, increased smuggling along the boarder and that they're trying to do the job. it's an impossible job.

and from the migrants' perspective, there's not really the negative expression that you would expect. they feel generally when they're picked up, they're picked up because they up need to be treated and go to a hospital, but also they've been treated quite well and sent back. >> host: professor hagen, when you were on the mexican side doing your work, were you ever fearful for your life? >> guest: no. i would be now. >> host: why? >> guest: because i think organized crime so interplayed with migration. so right now what you find increasingly is my grants -- migrants are relying on coyotes who are relying, renting space from traffickers; traffickers who are smuggling people, arms and drugs. so it's a much more dangerous game.

it's not the game that was played when i was down doing my research. it's become very dangerous. so high grants are not only -- migrants are not only confronting the dangers of the coyotes, but are also co-opted often into drug smuggling and human smuggling and arms smuggling. >> host: has the catholic church or other churches moved into the border areas, that last stage as you called it? >> guest: no, no. they're usually located in well established crossing towns and urban areas, and there's lots of desert, and there's lots of unfamiliar, arid, desolate territory, especially i'm thinking in guatemala where you have a lot of, you know, drug trafficking going on now. you know, as we came down on mexico and came down on colombia, we've really redirected much of this into central america.

>> host: what do you teach here at the university? >> guest: what do i teach? migration. international migration at the graduate and undergraduate level. i also teach family, and i've taught religion development, but my favorite course is migration. >> host: what's similar about the current migration patterns from mexico to the u.s. to past immigration in the u.s., anything? >> guest: it's, the composition has changed, there are more and more women, there are more and more unattached youth. so unaccompanied minors has become a huge part of the migration flow from mexico. there are more and more of the poorest leaving. it used to be that migration was more selective. you had to have some resources to make the journey. but the situations have become

so desperate, especially in honduras and parts of salvador. so it's really pulling the youngest, the poorest. more and more women, more and more danger. >> host: anyone make it on their open without spending on a coyote or -- >> guest: yeah. i mean, there are seasoned migrants that will travel in groups who will attempt the journey. but our border enforcement policy has really beefed up campaigns and selected crossing points where migrants historically crossed. and in doing so, they've diverted my grants to the more dangerous -- migrants to the more dangerous spots. so many of the, you know, the routes they're taking are unknown, uncertain routes. but, yes, many migrants they still, they still cross in groups and alone. and you have to go to a border town in mexico now, and there's just groups of migrants who have

been sent back and deported back, and they're just sitting there waiting for the opportunity to come back across. and when they leave, they'll be sure to stop and get the blessing of a priest. >> host: "migration miracle "is the name of the book. it's published by harvard university press. "faith, hope and meaning on the undocumented journal yi." jacqueline maria hagen is the author. >> guest: thank you. >> host: friday night at eight eastern with books on marriage equality, the obamas versus the clintons and the autobiography of former mayor of washington marion barry jr. saturday on "after words," bob woodward interviews john dean on the aerowear gait scandal -- on the watergate scandal. booktv, television for serious readers.

>> american history tv on c-span3 this weekend. friday night at 8 eastern, watergate 40 years later with a cbs special report and president nixon's address to the nation. saturday at noon eastern, a live call-in program with author and journalist john farrell on nixon's life, legacy and the watergate scandal that ended his administration. and sunday night at 8 on our series, "the presidency," jelled ford becomes the 38th president of the united states. this weekend on c-span3's american history tv. >> on c-span2 we're live at the national press club in washington where the alliance for health reform is holding another in a series of discussions looking at the impact of the health care law. this morning we'll hear about consumer choice and the adequacy of access to health care providers in the insurance marketplace. just getting underway live here on c-span2. >> so the title of this session is network adequacy, but we've

heard many names for these networks. we've heard everything from limited networks, narrow networks, value networks. why are we having so much trouble naming these things? first be, what are they finish first, what are they? some new insurance policy plans in the marketplace offer new consumers networks that do not include certain doctors, hospitals or other medical providers. some are saying that these smaller networks are causing problems for provider access choice while many are saying that if done the right way, this can help by creating competition and controlling costs while also maintaining quality. so there are a lot of questions about these networks. therefore, the trouble naming them. do they save consumers money? is the quality of care as good as in broader networks? do consumers have enough choice? do they need all that choice? how prescriptive should the federal government and/or the

state governments be in setting requirements for the networks? what is the consumer experience so far and what will it be going forward? so we're fortunate today to have three experts with us, and we are going to start with ted nick old today, wisconsin's insurance commissioner. he also plays a leadership role at the national association of insurance commissioners where he is a point person on this subject and is heading up efforts to update model regulations for the states. joe arrio to my left is managing director of manatt health solutions. he was the first director of the office of health insurance exchanges at the department of health and human services, he's been pennsylvania's insurance commissioner and also oregon's insurance commissioner. michael chernew is a professor

of health care policy at harvard medical school. he's a member of the congressional budge office panel of health -- budget office panel of health advisers and of the committee on national statistics. he's also a form toker chair, vice chair of medpac, the medicare payment advisory commission. once the three of them have given presentations, we'll open up to questions and answers, and at that time diane holder, who's executive vice president of upmc, university of pittsburgh medical center, and elena pavin who is manager within the value partnerships d. of the blue cross blue shield of michigan, will join us for the q&a. so we're going to go ahead and start with ted. >> good morning and thank you, marilyn, for having me here today. this is really a very important discussion, and it's one that's going to continue for quite some time into the future, but it really is, i really want to focus today on the issue of

network adequacy. and i'd like to just start out be i providing -- by providing a little bit of background and an update from a regulator's perspective on network adequacy. and it's, first of all, it's really important to know and to realize and to remember that there are a lot of conflicting issues surrounding network adequacy. for consumers the main issue is whether or not their doctor or their hospital is in their insurance plan and whether or not they can receive the care that they're looking for. and also whether or not they can ultimately be able to afford in particular their care and keep their health care costs down as well as their health insurance costs down. for providers, on the other hand, the wider the networks, the greater the reimbursement rates, the more attractive it is for consumers to pick from those plans and, thus, increase patient numbers. then providers are obviously constantly negotiating with

insurers for higher reimbursement rates. insurers view wide networks a little bit differently. they would, they would typically see those as increasing costs and decreasing their ability to managed care. insurers are constantly, again, negotiating with providers on reimbursement rates and to narrow at times networks to increase and better manage the care of patients and consumers. all of this is to a point. from the regulator's perspective, the networks must be sufficient or the insurer may have to pay in-network benefits to out-of-network providers. with the divergent interests all in play, how do we as regulators referee? is it really -- it's really a mixed regulatory approach. it differs from state to state. networks are summit to a number of -- are subject to a number of different reviews.

first is state review. the network must meet any state standards. then there are a number of, excuse me, then any number of insurers may try to and become accredited by national accrediting firms such as ncqa or, uraq. this is often times used as a sign of quality, a good housekeeping seal of approval. for insurers selling on an exchange or opting for a qualified health plan designation, they also must follow federal standards. again, from a regulatory perspective, who do we regulate to assure network adequacy and folks following networks? for the insurer do we regulate the insurer, do we regulate the network itself, do we regulate tp as? for a fully up sured plan, it's

pretty simple. -- insured plan, it's pretty simple. the regulated insurers can regulate the plan through that process. for a self-insured plan, it's not quite as clear. as a result, some states have looked at regulating third party administrators to get to the issues. most states will only be able to regulate the issues through the insurer oversight function. it's also or not to note that there hay be different standards -- there may be different standards for different products. in wisconsin, for instance, an hmo or closed panel may be required to report more quality measures or required to allow access to certain providers such as an ob/gyn. they may also have certain appeals processes in place for emergency care. ppos and open panel plans, on the other hand, may have lesser requirements because consumers do have an option to choose from any provider. one of the other debates at some point may end up revolving

around this business of multitier plans where one of the plans has very small co-pays, one of the networks has very small co-pays, and a larger network is attached to that with higher co-pays and out-of-network benefits. the question might be do we look at these tears, how do we look at these tiers, should the smaller tier be regulated, and should it have to be a full network? typically, that tier level does not include specialists. all this is to get at my next point. many cases in the past -- excuse me, in many cases the passage of the aca has resulted in the accelerated use, focus on and narrowing of networks across the country. hearken back to my earlier point that more control or lower networks can lower costs for insurers. wider benefits under qhp, under

aca have increased the cost of insurance. insurers, to keep insurance costs lower, look to network designing. we have re-examined and updated the model law. not unusual, but usually -- usually environmental factors cause the naic or the normal vicissitudes of time to update our model laws. the current naic model has not been looked at or updated since the late 1990s, but states are still able to make their changes, the states that have adopted the model have been able to make their own changes at any time. the model was adopted in 1996 and very flexible and is still very good. its ply about reflects the diversity that exists between states both in terms of market differences -- large versus

urban, excuse me be, large urban versus vast rural and the way insurers operate, open panel versus closed panel. but still keeps the same standards. the model itself requires a sufficient number of and types of providers to deliver all covered is services or provide coverage at no greater cost to the consumer. also provider distances and wait times should reflect the norms of the area. it further requires insureers to file an access plan to insure they are meeting standards of the area. wisconsin chairs that group, and it's charged with revising the model. as chair, we've sought a lot of input from all parties affected by the law; consumers, providers, insurers and accrediting organizations. we've received 26 comments thus far, comment letters thus far from interested parties, and once we're finished reviewing those, we'll continue working on revising the model. and the goal is to add all of

those changes or look at all of those changes and then take a fresh look and go through the model one more time. great deal of important questions to ask in and around network adequacy. in some cases we may not be able to come up with an answer. as a regulator of insurance, it may not be our place to answer. issues that we'll be grab being with include are narrow networks each a problem? what if no wide networks are offered in a particular be market? what if an insurer does not offer out-of-network coverage? how narrow is too narrow? what does it matter if an insurer -- does it matter if an insurer covers all out-of-network services? what is the appeals process for uncovered services? should there be a single, statewide standard? what happens when a doctor or hospital leaves a network? and to what degree should continuity of care requirements there be, should there be? and then, of course, consumer notice requirements as well. the list goes on and on.

finally, i just wallet to keep -- we as regulators and folks working on this very important issue need to keep a couple of things in mind as well. we always need to be mindful of cost. we need to look at access to medical care for vulnerable consumers, and we need to recognize and understand that we, as regulators, do not have all of the answers. the bottom line is that we need a model that can address the existing and emerging issues for another 15 or 20 years. with that, i'll turn it back to joel or michael. >> okay, great. >> thank you. >> actually, before we move on, can i just ask you what can you tell us at the moment? i understand that you haven't finished your work at the naic, but what can you tell us about where you think we're headed with these regulations? are there any -- based on the comments, based on where the other insurance commissioners are, what can you tell us about where you think we're headed with these regulations on some of these questions that you

raised? >> that's a -- [laughter] that's a broad question. it's, it's clear, and i was talking to some of my fellow commissioners, regulators last week, and it's clear that this business of state, state-to-state differences needs to be recognized. we have states with significant urban populations, and then you have states like wisconsin with pockets of urban populations surrounded by cows. and it's important to headache sure that there's -- to make sure that there's a model in place and there's a framework in place to get, ultimately, get consumers the type of care and get the consumers the type of access they need. but, again, keeping in mind, keeping in mind the cost issues.

the other issue that we've seen so far is in talking with other regulators, in talking with some of my staff this whole issue of network adequacy. while always being something we get complaints about or something we get questions about, we have not yet seen an uptick. we haven't seen an uptick in the amount of questions about, gosh, you know, my insurer canceled my network, or they threw out my doctor, what am i going to do? we're not seeing that yet. so we're trying to keep all those things in mind as we look to, again, update the model. and update it with an eye toward, an eye toward there's new products out there. there's new technology available. there's a lot of just -- the

entire health care marketplace, the entire health insurance marketplace has changed since the model was passed. so we're, you know, heading in that direction of updating the model given a lot of the environmental factors that we've been experiencing, that we've seen. >> okay, great. and one more very quick follow-up question, then we'll move on. regarding the comments that have come in from stakeholders and others, are there any particular themes that you, threads that you saw this those or any distinctive disagreements that you think are going to make it, make your job a lot more difficult? >> i think the one issue that's always going to be, that's always going to be a challenge is access. you're going to want some -- there's going to be certain folks that want to have just complete wide access to whatever's available out there, and you're going to have the

other side pushing back saying that's a great idea, but it's just not affordable at that level. and you're also going, you're also going to -- we've seen that there's a need for more managed care. there's so much more technology out there. there's so many ways to better handle individual care. and i think joel's going to address it at some point this morning, that this idea of focusing and narrowing of networks and better managing care is really becoming a huge part of the landscape, and it's really, it's really promoting healthier outcomes. and so there's going to be that, there's going to be that struggle. there's going to be those back and forths on, you know, wider the better versus narrower the

better, and i think that's what we're going to be really grappling with as we look at updating the model. >> okay. so let's move to joel now. >> okay, thank you. i always enjoy following ted at these kinds of events because it reminds me why i loved my years in the naic. a sense of deep knowledge of the issues, a sense of knowledge and professionalism about how to handle them. i think on a lot of these issues looking at the naic and the different states and the way they're represented is a good way to get a window into those issues, so i thank ted for his comments, and i hope we do keep this issue at the state level because i think it differs dramatically across the states. one more comment i want to make is the last time i was here at the press club, it was for an event that sean clark organized and asked me to attend and then shortly thereafter i learned of his sudden death, and so i just want to take a moment of personal privilege to commemorate sean. he was, i think, a reporter in

the very best tradition, just a natural curiosity about issues and just really did a bang-up job of covering these issues particularly at the naic. so with that, i'll get into my comments. i basically have three, three points to make. one is around the networks and what was intended in the aca in terms of setting up the exchanges and competition within the exchanges. two, what are some of the broader issues within the aca that relate to the network issue foreshadowing, ted foreshadowed that with the managed delivery systems and so forth. and then, three, what are some of the consumer concerns here? because i think, ultimately, consumers will be the barometer on this issue, and if they react like they did in the '90s to some of these narrowing of networks, you know, we're going to have a different outcome than if they see it as one choice among many in a market place. so starting with the first

comment, narrow or value networks, i'll try to use both terms. shows you how controversial the issues are. you get in trouble right away depending on what you call these things, but narrower value networks, i think, were clearly intended in the aca. they're, when you take out a lot of the other variables that insurers are used to competing on, particularly risk selection, i'm glad that's gone as a form of competition. maybe it's not completely gone, but it should be gone, and it will be gone. then you have to look at other ways to compete, and i think it was pretty clear as the aca was set up that one of the things that insurers were going to do to compete with each other was really ask hard questions about their networks and try to manage price around how they set up their networks. it was also envisioned, i think, in the aca that part of the reason that would work was because the exchanges would offer a multitude of choices to people. so this wouldn't be like your employer deciding to go with an

hmo as the only product and suddenly you're forced into a very narrow network and it's a one-size-fits-all situation. the exchanges allow you where if people wallet, they can choose -- want, they can choose broader ppos. and i think that's very important. and if i were running an exchange, i would want to make sure that all the products weren't their row network, tightly managed type products, that there were some choices for consumers out there in the fpo world. -- ppo world. that means the consumer has to be educated and has to know the difference between those kind of issues. but i think, so the first point is this is not a surprise to people who put the aca together. this is what was intended in the aca, to have this kind of competition, and it's a healthy kind of competition to have in the market place. and if i feared one thing more than anything else in this whole arena, it would be that some events happen that cause people

to sort of set a one-size-fits-all type solution that takes away the rich kind of competition that can happen around different approaches to networks. that's point one. point two, if you look to the rest of the aca outside the exchanges now, you do see the kinds of things that ted talked about right at the end there of the acos, affordable care -- accountable care organizations which could be called affordable care organizations too. but the acos and really other dimensions of the payment reform initiatives that are coming out of cmi, the innovation center, bundle payments, they all require tightly-managed oversight of provider networks and integration between the provider network and the insurer. you could call them kaiser-like approaches to the issue. i know when i was at the agency when we were setting up the original kind of network rules and some people were opposing,

you know, fairly stringent kind of standards that would apply to everybody as we were just kicking around ideas, i would always ask the question, well, what would you do with kaiser under that situation? and people would go, oh, kaiser's different. and i'd say, well, what about other people that are going to say when this law's in place we want to be kaiser? you can't just say kaiser's different. you've got to let everybody be, have an opportunity to do that, or you say you can't do it at all. and i think those kind of integrated delivery systems are very important. we saw on earnings calls last week, cigna, aetna, they both talk about the importance of having some flexibility around networks and how their aco work -- which they're busy creating acos in conjunction with their insurance activities -- that those become examples of products. and i think, ted, you have some of them in your state now. the chinese plan in san francisco, you're going to create these plans in local areas that have a select network

that works this that -- in that local area. and if i'm an exchange director, i want those product on my exchange. not as the only products, but i do want them. in some ways the insurers have to be pushed to create these products. in massachusetts it was the legislature that had to say we want all the insurers to offer a product with a lower price point with a narrower network because we want that choice available. so i think all of that is important here. it's intended for price competition, but it's also key to managed care and improving the quality, the triple aim of improving the quality at the same time you're reducing the costs. the way in which networks are managed are critical to that, and i think the future does hold that a number of these aco type developments that are happening around the country will show up as products, targeted products on the exchanges. so that gets me to the third, probably the most important point because, again, i think consumers are the ultimate barometer here.

the insurers, the politicians, everybody that's part of this system, even the insurance commissioners depending on what consumers say and how they vote in the marketplace, will react to that. and the rules will differ. so i think two issues are important to make for a vibrant and competitive network out there. one is transparency. the consumer does need to know who's in what networks and which plans are which kind of networks. i'm likely to the see a kaiser being challenged on -- it's unlikely to see a kaiser being challenged on its networks because people pretty much know what they're getting there, it's more or less a closed system. it's a much different thing if a broader plan that's got a reputation and advertises itself as, you know, we have all the doctors in our state in our networks and so forth and then somebody buys that product and they say, well, there was actually small print over here that said the particular product you bought, that's not part

of -- you don't have that broad network, you have something else. you should be able to do that. but it's got to be very transparent. the consumer has to understand what they're buying. so i think there's a lot of work to be done, and i look to the naic around those kind of issues. and then finally i think there have to be some kind of safety valves for out-of-network protections if you're going to draw a tight line around the network and pretty big penalties if you go out of network or maybe you don't get any reimbursement in some cases. then you have to have rules like i go to the in-network hospital, and then i get a bill, oh, by the way, the anesthesiologist is not in network. that kind of thing. new york now regulates that and says if the consumer doesn't know about it ahead of time, then they get the in-network price for that sort of service. so a lot of issues here to make sure that consumers are educated

around these issues and that there's full transparency. but within that, i think it'd be wise and i suspect that the naic will come to this kind of conclusion that we ought to the give states fairly wide latitude to regulate this in response to local market conditions. >> okay. great. so let's turn to mike chernew. >> great, thank you. and i am thrilled to be here. when i speak at events like this, sometimes there are speakers who disagree, and there are a lot of fireworks, and it's pretty exciting. unfortunately, i'm actually going to be in agreement with the previous speaker, so for the viewers who wanted a jerry springer type event, i don't think we're going to have one today. [laughter] maybe later. so, first, let me start by saying something about the term narrow versus value. value and narrow are not synonymous. narrow networks may be high value networks, but value implies something about cost and quality, not just cost. and so value has a very specific meaning about what you're

getting for the amount you're paying which is not simply to be equated with narrow for the sake of -- you could have a high value narrow network, but you might not, and i think the entire discussion here is what to do when you have a their roar network that's not -- narrow network that's not potentially high value. so let me start by at least trying to lay out a general conceptualization. one of the things i sometimes find frustrating is when i read articles, the topic du jour is one area, then they move to another area, and they, of course, forgot everything that was written last week. there's been a lot written in the u.s. about the prices that we have that are high, and that's an issue. so one advantage of having narrower networks -- and member i say price, i don't mean premiums. i mean the price that are paid to providers. one advantage of narrower networks is it strengthens the negotiating hands of the people who are purchasing. so i had a friend that, unfortunately, he said when buying a car in front of -- to his wife in front of the

salesman, i don't want care what we do, we have to get the car today. [laughter] which, you know with, it was interesting to say it wasn't that useful in the negotiation process. so if you, if you're negotiating and the other person knows they have to be in, it changes your ability to negotiate price. so if you're worried about price -- and you may or may not be -- but if you are, in a market system the ability to exclude people becomes important in that type of negotiation. another topic that's been very interesting, we did some work on this topic, it was geographic variation. it's widely known there's variation across geography and actually across providers. there are providers that are more efficient than other providers. if you knew that, wouldn't it make sense to try and construct a network that focused folks on those providers that you thought were more efficient? that ends up being an advantage of having a narrow and in that case probably more of a value network. there's other reasons why these narrower networks are good. you can -- if you can

concentrate enrollment amongst fewer providers, it facilitates engagement and it may reduce administrative costs. so i think i can make a pretty strong case why there's some merit for these types of things. but that said, and you'll now realize i'm an economist because i'm about to say on the other hand -- [laughter] there's a lot of legitimate reasons to be concerned about these types of products. host importantly, people need access to good doctors, they need access to convenient doctors, they need access to their. doctors. and we very much want to have people have that opportunity. the problem is, in general, you choose your plan before you get ill. so it's not clear you know who your doctors are. i'm a reasonably healthy guy. i can name one doctor who's my doctor can. there's a lot of things that can go bad, i have a lot of body parts, all of them can break. i have no idea which doctor i would want to go in that eventuality, and i would be

forced to choose my plan -- i don't want to investigate who the best neurologist and dermatologist and whatever ologist i might need before i choose my plan. so i can't make that choice. even though i agree with the other speakers, consumer awareness and information is important be, there will be limits to how much we can inform consumers because of the time when they choose their plan versus the time when they need their care. and in the case where you might need to use a lot of doctors, it may be difficult to get the doctors that you want into the plan. so, for example, i only have one doctor so i can take my primary care doctor where they are, but i might not know -- if my mother had a lymphoma, she had a very good relationship with her oncologist. she could have been put in a position where she had to choose between her primary care physician and her oncologist. there are many cases where people have very serious and important relationships with their physicians, and in these models it is difficult to say to certain people, well, now you

have to choose, and we have to figure out how to balance that concern with the other advantages that i mentioned before. so transparency's, obviously, important. it's not going to be a full solution. regulation of network changes, i think, matters. there's a concern about a bait and switch thing you might happen. you join a plan you thought your doctor was in, then it turns out the network changes. all of a sudden your doctor's not in, and you're stuck, and we have to think about how to deal with that. and i think both of the other speakers said and i think it's really important be one of the ways to deal with this type of problem is to reduce the consequences if your physician or your hospital for that matter ends up being out of network. what do you have to pay if you have to go out of network to reduce the harm that occurs if there's some mismatch between the doctor that you want or need and what your network looks like. there's another problem with, another concern i should say

about these types of networks, and that's the concern related to selection. it is true that i can make a compelling case that there's variation and efficiency across providers, and we'd want the insurers to be able to pick physicians that are more efficient. you hine able to pick -- you might be able to pick certain types of patients by picking certain doctors. i believe, personal comment, we have made sufficient advances in risk adjustment that i am less concerned about that. in fact, i could show you some academic evidence that superintendents it might be more appealing to have folks with chronic disease in as opposed to out because of the way we do risk adjustment, but that remains to be seen, and we are certainly at the beginning, not the end, of this process. so i think that that matters. a few other sort of final points. the first one is, and i really hate to say this, but i do believe this. fairness to providers is important be, but it is not the fundamental goal of the health

care system. i do believe, just on the record, i do believe we have to be fair to providers. but the ability of a provider to get into a network is not ultimately what we're concerned about, we're concerned about patients having access to the care they need at a cost they can afford. and we will see, i believe, through these networks a big deliver and how the provider system responds, and how that plays out will be the most important thing to monitor as providers find themselves in a somewhat more complicated environment because they're going to have to negotiate potentially with different plans. a few other things. as was mentioned before, i do think we need to begin to think about these issues of network adequacy as market. that creates great challenges for the regulators which is glad i'm not one. but i do think that really does matter a lot, and we have to focus on that. the second thing is, um, ideally

we would be able to focus on measures of outcome, not structure. focus on the quality and the access, things that were mentioned as opposed to focusing on structure. it is always very hard and i think will remain to be very hard if we focus be exclusively on aspects of structure, and i think the more we can improve our measures of outcomes, the less important the decisions we make and the easier it will be to make decisions about the underlying adequacy of things because we will be able to make sure that we can at least avoid the most egregious cases of where there are problems. in summary, we will not get this perfectly correct. there will be complaints for a variety of reasons, many of them are likely to be justifiable complaints, but we are going to have to avoid the temptation to move to a system that prevents any type of creative network development because we want to avoid there ever being a problem when those networks do get developed. so thank you. >> thank you.

so before we head into the q and a, one question for the three panelists and that is what do we already know about cost and quality between if you're comparing the narrower networks to the broader networks? do we have any numbers, research that show us our experience already in terms of cost and quality? >> one thing i can jump in on here with all of the data that's now available for research, what we're seeing and what's being seen by some of the insurers is, in fact, that higher prices for services does not necessarily indicate better outcomes. what we're seeing is providers that are doing, let's say, doing

knees, rebuilding knees or fixing knees. the more they do it, the more familiar they get with it, the better the outcome, and because they do so many of them, often times the price of that particular, that particular procedure is lower than it is for the guy that does one a week. the they're doing one or two or three a day versus one a week or one a month. what we're seeing in terms of the outcomes is that, is that often times the lower cost procedure is really producing better outcomes. >> i think on price we know that narrow networks end up cheaper, and i think we -- and we also know we're seeing a lot of narrow networks in the exchanges and, therefore, prices are a little lower in general terms than we expected going into the exchanges. on quality i think it's pretty much anecdotal still. my view is we don't really know yet very much about how to measure quality, but there are a

few things we do know and one of them i like to point out is that if you look at who scores well on the medicare five-star system which is, you know, one of the systems out there that's kind of leading the way on measuring equality, again, the caveat i'm not sure how well it does that, but to the extempt it does -- extent it does measure quality, if you look at the highest achievement under that system, it tends to be the achp companies which are the integrated companies, diane's company, kaiser, group health, intermountain, the groups that have integrated delivery systems do tend to perform better on that medicare system. >> and just, actually, just before you jump in, you mentioned the medicare and the system for medicare advantage, and the federal government is looking at some new standards that will be similar to medicare advantage. is that what, where we should be going? and how is that going to work? >> the federal government did

hold up the quality initiatives under exchanges for several years, and one of the main reasons for it was that they wanted to make sure there was alignment across these different federal programs. so the last thing we want, i think, is one approach to quality in exchanges, a different one in medicare, so there's a lot of different work going on to align these things but, again, i think we're still pretty primitive. part of it is if you look at consumers, they don't tend to pay a lot of attention to those ratings. you can find examples where they do, but i don't know that they know how to mash quality very well yet -- measure quality very well yet. >> okay, mike? >> well, i think joel's exactly right. the analogy to this discussion is if we looked at the managed care experience in the past which budget a resounding success in a -- which wasn't a resounding success in a variety of ways. but i do think the evidence suggests those plans were able to have a somewhat lower cost and perform well on the state of the art quality measures at the

time. the key phrase there is at the time and, again, joel's right. the interesting thing there is the narrowing of the networks in those plans was not the defining feature of those plans. the narrowing of the network in those plans enabled them to do a whole series of other things in those organizations. and so i think it will be a mistake particularly given where we are in the process now to try and generalize about these plans. i am sure there will be some exceptional ones that can provide both low cost and high quality care regardless of how you measure high quality care most of the time. i am also sure there will be some that won't be quite as good. the challenge here is to try and set up a system that both identifies, informs and monitors those that are falling on the part of the santorum that we don't -- of the spectrum that we don't like. and i think it's going to be very challenging to try and generalize about anything about what these types of networks do because they're going to be local, they're going to be done by different organizations with

different abilities to manage them well, and they will have as part of the network portion a series of other tools layered on top that will vary. so you're not talking about just the network, although that's what our topic is today. there's a whole bunch of other things that will occur related to the managing of the care and a bunch of other things that will define the outcomes that you want, and we're going to live with heteroyes nayty and to have consumers to choose among them versus limit their choices for various reasons. >> okay. so we're going to open up for q and a now. i want to remind those who are listening on the phone line or watching on c-span2, you can e-mail questions to questions@allhealth.org, or you can tweet them to hashtag networkadequacy. i also want to remind everyone that we have two on-the-ground experts with us, we have diane

holder who's with the university of pittsburgh medical center, and she can give us an on-the-ground perspective as well as elena pavin who's with the blue cross blue shield of michigan. so we have some on-the-ground experts, so they will be joining in on the conversation, and you can direct your questions to anybody on the possible or just to the panel in general. and when you ask your question if you could, please, identify yourself. yes. >> i'm peggy eastman with oncology times. i guess my general concern would be regarding centers of excellence, their exclusion, for example. if i were diagnosed with cancer, for example, i'd want to go to a national cancer institute designated center of excellence. and those should not, in my view, be excluded for any disease. so i guess my question is, um, will, in fact, most of these networks provide access to

designated centers of excellence for various diseases? >> diane, you might want to talk about what just happened in pittsburgh because they settled a case between two with insurers who were arguing about networks, and certain facilities that upmc has, particularly the cancer facility be, it does these to be a network for both of these insurers who are essentially going to have separate networks over time. i think the point's well taken. you might want to have a tiered pricing approach be, maybe some pricing difference for the consumer depending on where they choose to go, but i think cutting off completely access to certain kinds of facilities probably isn't going to work very well with the consumer. >> well, the other thing is it might save money in the long run if the initial treatment choice is the best one. >> and if you have that choice, i mean, have that treatment, then it might, you know, prevent more treatment down the road. >> yeah. i heene, i think one of the

things -- i mean, i think one of the things that is really at the heart of this debate is what really is adequate. and when you look at the outcomes people are trying to achieve and they want clinical outcomes that are an improvement than what we have, you know, in many regions and really across the country, we suffer from some deficits in our quality. you know, the struggle, i think, that people have had gets to the heart of what michael said which is a network's not a network, not a network. and a narrow network is not a network. it's really about what is it that the people need in a region and how do they get access to the right combination of cost and quality? and so i think there are certain minimal standards that have to be met and certain minimal access points. and it has to be balanced with both provider and insurance competition because we're not going to get the kind of innovation we need if we stand in the way of trying to do things differently than we've done them this the past.

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>> there is a formal and informal appeal process built into the system and i can think of one in wisconsin where the someone called the department and said i cannot get this treatment so i need to go somewhere else and need a way to get there. we made it happen and that person is still alive because of that. that is the role of the regulator. you know? if we play it straight down the line when those situations come up. but in term of rewriting the model, that is going to be discussed. the ability to file appeals for an emergency or specialized care

and former or informal needs so they have an avenue to pursue. >> this seems like an opportunity that insurers haven't had in a while and it will compel hospitals to align prices and a hospital response. we get hospitals in dallas that compete on if they are a four-star hotel or their thread count for bed sheets. and you don't see anything that gives the insurers the ability to say wait a minute. if you want that you can buy it. but adequacy doesn't include

four-star network. >> back in the '80s and '90s people thought they would have a narrow range but they voted against that. and i am not sure it is anticipated there would have been such a demand from that. the challenge is separating the bed sheets out from the great cancer care. it is a question as to what level of quality and separation we would want and when we would want the consumer to make the choices. i think the discussion today is how to create markets that work in a world where information is imperfect and we care about the outcome in a way we don't for other things. if you buy a third rate

cellphone, i am sorry, but if you end up getting bad cancer care i feel differently about that in a variety of ways. i think we will see and i think we should allow consumers to make choices as to what they can get access to the care in the network and the breadth of their network. but we have to have a lower bound that is acceptable and regulate the processes around it so that some of the bad things that might happen in that world are minimized. >> dallas is an ideal place too this competition because there is multiple health care systems down there so there can be good competition in the way you described. the other side is some parts of

the country this is what happens. there is not the same leverage to use network strategy to drive price. >> another thing that is a hot topic and another issue is anti-trust. so if you see this competition and you are a provider you see mergers. so there will be aspects of network consolidation and we could have another press briefing on this. but we want to maintain competition amongst providers so many of the issues in the forefront of the policy maker's minds overlaps and one of the themes for all of us is ending up with a system that works and

one we have to put regulatory barriers to that type of competition. >> yes? >> this question is for ted. cms this year decided for 2015 it was going to, i think, put in place more strict network adequacy standards for the plans offered on the federal market place and it suggested in the future they might look at standards around time and distance requirements. do you think they should be in the business of doing that given what you said about recognizing state-by-state differences? >> i love my friends at the federal government. but i am very leery and wary and concerned if folks at the hhs come up with some sort of floor.

i know i have fellow regulators who would like a floor. but given the diversity of market places throughout the country what i don't want to have is an extra or heavy push by the federal government to get into the business of someone that states do very well. they know their markets and market places and distance and rural versus urban. we don't want our friends in washington, d.c. or maryland to put something in place that will mess up a strategy that is working well in a state and they should do it at the state level to make the decision and manage

the market places. >> i would like to ask if the only panels want to weigh in on the question on the federal versus state or is there a combination of both that would work and also where are we headed and what is going to happen with federal? is the federal government moving forward? >> i have a comment from the michigan plan. we would want the ability to do that in our own communities. and we have areas where we don't have providers because there is no doctor in that area. it is complex for patients in rural area and where they go to access care and how expensive is it. as a plan, there is a way to work with providers in a partnership and develop programs where you have a team between the plan and providers to

develop high-quality, low-cost care for those parts of the state. so we agree with the flexibility of allowing states to do the work. >> we did sign-up for federal and that was equalitative standard. i think there are wrinkles here and one is the exchanges have more low-income people coming into the market place than traditionally so there is a second part which is essential community providers that serve that population and there we did start with regulations that were 20% of all of the community tries to make sure the providers in low-income populations would be represented and they raised it up to 30%. it illustrates that all

generalizations are false in a good mantra to keep in mind when you think about these issues. >> i would like to follow-up maybe with question from mr. nic nickel. have the medicare advantage standards created problems? those that have five different levels based on the diversity of the community and total population density? have they failed to represent the diversity among the states? >> that is not a question i am well versed on. i have not heard or seen much in terms of complaints on the issue but i would have to get back to you on that. >> joel, you mentioned medicare

advantage before. do you have something to say? >> they are set for a particular population group, the elderly, and to import them into the broader network place probably wouldn't be the best solution but i would look at some of the principles that are there. i think whoever makes the rules for the group where you earn your pay, should there be a quantification and everybody starts with time and distance rules and there are those in the medicare standards. do we need that or a national forum? i would be unsure of doing that but that is where the rubber will meet the road in the discussion. >> the medicare advantage has one difference from the

exchanges and that is the existence of medicare. you have this market backdrop in the advantage world, and most people opt to stay in the traditional care. but in the exchanges you don't have a broad plan you could automatically pick so in the exchange population we are worried as again, in some ways as mentioned earlier on, not so much if there is a plan that is narrower than you like but a market place where there is not a choice you would want. in the medicare advantage system the existence of medicare relieves a lot of pressure on the advantage plans. >> related to this loosely the national committee for quality insurance came out with an accreditation of plans. how is that going to work?

is that going to work well? how does that fit in with all of the other parties are doing? >> i think it a welcomed development in terms of they can be helpful and a level below regulation. on the federal level you have to worry once a regulation is put into effect it is hard to change. the states are more nimble about trying something out and that is not the experience at the federal government. so looking at things through accreditation versus permanent regulation are to be commended. i don't know a lot about the standards but they seem to be more processed oriented and not

so much on strict bottom line standards. again, i could be wrong on the details but that was my impression. more process standards examples. >> i think you need to read the activity as a subset of any enormous new movement to inform people and provide information about the types of plans. there is a lot of venture capital, a range of new companies that are trying to find ways to inform people about the different plans and inform people about the different providers within the plans and inform them when they are choosing a plan and inform them when they chose a physician. you will see a lot of efforts to improve the way the markets work. we are at the beginning of understanding how well all of those sort of new tools to they